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PLATE I 



Mottled eruption 
from the arm of 
same case. 





Severe Case of Scarlet Fever, showing eruption at its height. For 
strawberry tongue of same case, see Plate XVII. (Original.) (Painted 
from a case in the Riverside Hospital. ) 



DISEASES 



OF 



INFANCY AND CHILDHOOD 

THEIR 

Dietetic, Hygienic, and Medical Treatment 



A TEXT-BOOK DESIGNED FOR PRACTITIONERS 
AND STUDENTS IN MEDICINE. 



BY 

LOUIS FISCHER, M.D. 

ATTENDING PHYSICIAN TO THE WILLARD PARKER AND RIVERSIDE HOSPITALS OF NEW YORK CITY 

ATTENDING PKDIATRIST TO THE SYDENHAM HOSPITAL; FORMER INSTRUCTOR IN DISEASES 

OF CHILDREN AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, 

ETC., ETC. ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE. 



FOURTH EDITION 



WITH THREE HUNDRED AND EIGHT ILLUSTRATIONS, SEVERAL 
IN COLORS, AND THIRTY FULL-PAGE HALF- 
TONE AND COLOR PLATES 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 

1911 



i 



4? 






COPYRIGHT. 1907 

COPYRIGHT. 1908 

COPYRIGHT. 1910 

COPYRIGHT. October, 1911 

BY 

F. A. DAVIS COMPANY 
[Registered at Stationers' Hall. London. Eng.] 









Philadelphia. Pa.. U. S. A. 

Press of F. A. Davis Company 

1914-16 Cherry Street 



©CU297439 



TO 



ADOLF BAGINSKY, M.D. 



.PROFESSOR OF DISEASES OF CHILDREN AT THE BERLIN UNIVERSITY, AND 

DIRECTOR OF THE EMPEROR AND EMPRESS FREDERICK 

CHILDREN'S HOSPITAL, BERLIN, 



AS A TOKEN OF GRATITUDE FOR HIS MANIFOLD COURTESIES 
THIS WORK IS MOST 



AFFECTIONATELY INSCRIBED, 



I 



PEEFAOE TO FOURTH EDITION. 



Sciexce has again reversed many existing theories pertaining to the 
causes of gastric derangements. Clinical and microscopical observations 
have shown that casein, rather than being a disturbing element causing 
intestinal autointoxication, is really a valuable adjuvant in atrophic con- 
ditions, as it modifies intestinal putrefaction. I have accordingly rewritten 
articles on fat, sugar, and casein. A study of infantile disorders of 
nutrition is most important, because faulty nutrition means faulty assimi- 
lation. A new article on faulty metabolism has been added. A new 
article on stools is added. Xew articles on phalangitis, angina Ludovici, 
and rectal polypi are added. 

The etiology of poliomyelitis has been modified since the recent work 
of Flexner. The laboratory has also added a new method of diagnosis in 
meningitis by examination of the cerebrospinal fluid. Brudzinski's sign 
is added in the chapter on cerebrospinal meningitis. 

To differentiate pyloric spasm from true pyloric stenosis is simplified 
with the aid of a miniature duodenal bucket. 

My personal experience with salvarsan in this city and in Europe 
has given me an opportunity of testing the merits of this new therapeutic 
adjunct in syphilis. 

To make room for better and more important illustrations some minor 
ones have been omitted. I have added an illustration showing the bacteri- 
ology of tonsillitis, one showing desquamation in scarlet fever, two of 
syphilis, and one of meningitis. 

Louis Fischer. 

162 West Eighty-seventh Street, 
New York City. 



(iv) 



PEEFACE. 



Eapid strides have been made in the diagnosis and especially in the 
treatment of diseases in children. The twentieth century has perfected 
many dark points in pediatrics. Along with the progress in diagnosis, 
therapeutics has been entirely remodeled. 

The development of bacteriology has added new methods of diagnosis, 
aided prognosis, and further perfected specific treatment for various infec- 
tious diseases. A comparison of the treatment of diphtheria in vogue 
twenty years ago with that of the antitoxin treatment of to-day, is cited 
as an instance of progress. The operation of intubation instead of trache- 
otomy for acute and subacute obstruction to the upper air passages is 
another instance of progress in therapeutics. 

Our advance in the diagnosis and the modern treatment of tubercu- 
losis has been the means of saving many lives. 

In this work, infant-feeding in all its phases, maternal nursing, wet 
nursing, and hand feeding with all home modifications for bottle feeding, 
are carefully considered and given special attention. The disorders arising 
from improper feeding have been given prominence owing to the impor« 
tance of the subject. 

The growing child is very susceptible to infectious diseases, hence 
this important part has received my most earnest attention. The diseases 
of the digestive tract and diseases of the respiratory tract have in their 
turn been considered. 

Clinical observations in Europe, as well as while on duty as an attend- 
ing physician to the large service of the Eiverside and Willard Parker Hos- 
pitals, have given me an abundant opportunity for comparing various 
methods of treatment. 

This book has been divided into twelve parts: — 
I. The New-born Infant. 
II. Abnormalities and Diseases of the Xewly-born. 
III. Feeding in Health and Disease. 

IV. Disorders Associated with Improper Nutrition, and Diseases of the 
Month; (Esophagus, Stomach, Intestines, and Eectum. 
V. Diseases of the Heart. Liver, Spleen, Pancreas, Peritoneum, and 
Oonito-urinarv Tract. 

(v) 



I 



VI 



PREFACE. 



VI. Diseases of the Bespiratory System. 
VII. The Infectious Diseases. 
VIII. Diseases of the Blood, Lymph Glands or Nodes, and Ductless 
Glands. 
IX. Diseases of the Xervous System. 

X. Diseases of the Ear, Eye, Skin, and Abnormal Growths. 
XL Diseases of the Spine and Joints. 
XII. Miscellaneous. 

The greatest stress has been laid on the diagnosis, symptoms, and 
treatment which are so necessary at the bedside. Pathology and more 
especially Bacteriology have been given ample consideration. 

An intimate acquaintance with the needs of the physician, while teach- 
ing Diseases of Children at the Xew York Post-graduate Medical School 
and Hospital, has proven the value of photographic and color plates to 
express the true nature of disease. For this reason, in almost every article, 
I have used liberally, clinical and pictorial illustrations of cases. 

Due credit has been given in the text for some photographs loaned to 
me. The staffs in the various hospitals have given me liberal assistance 
and, in many instances, practical advice. 

I desire to acknowledge the kind assistance of Drs. D. Ashley, H. T. 
Brooks, Wolf Freudenthal, Archibald E. Isaacs, Herman Jareck}^, M. D. 
Lederman, and L. S. Manson for suggestions in the special articles per- 
taining to orthopedics, pathology, ear, eye, throat, and nervous systems. 

Most of the original half-tones and colored illustrations were made 
by Mr. Henry C. Lehmann. I am especially indebted to him for pains- 
taking care in the illustrations of diphtheria and scarlet fever made for me 
at the bed-side of cases in the hospital. I desire to acknowledge the liber- 
ality and uniform courtesy which my publishers have extended to me. 

Louis Fischer. 

65 East Ninetieth Street, 
New York City. 



CONTENTS. 



PART I. 

Development and Hygiene oe the Ineant. 
Diagnostic Suggestions. 

CHAPTER PAGE 

I. — Infancy and Childhood 1 

The new-born infant; infancy, childhood. 

II. — The Development of the Various Senses 2 

Reflex actions; sighing; urine; suckling or nursing; supporting the 
head; sitting; playing; stamping with the feet; the first attempts 
at walking; laughing; kissing; tears; memory; taste; touch; voice 
sounds; very late speaking; sudden loss of speech due to paralysis. 

III. — The Development of the Body 5 

Growth and height; dentition. 

IV. — Diagnostic Suggestions 9 

The pulse-rate; respirations; temperature; eye; gestures; cry; 
tongue; throat; sleep; the value of X-ray in diagnosis. 

V. — General Hygiene of the Infant 16 

Hygiene of the mouth and teeth; management of the navel; the um- 
bilical cord; vernix caseosa; bathing the baby; clothing; the nur- 
sery; ventilation; when to take an infant out-of-doors; the nurse- 
maid; method of heating the nursery; light; furniture; bed and 
pillow; proper training of bowels and bladder; hygiene of the nervous 
system; exercise. 



PAET II. 

Abnormalities and Diseases oe the Newly-born. 

I. — Premature Infants 24 

Management of a premature infant; method of feeding; premature 
birth; artificial feeding. 

II. — Prophylaxis and Treatment of the Eyes in the New-born 32 

III. — Diseases and Malformations of the Umbilicus 33 

Granuloma; diphtheritic omphalitis; dangers incident to careless- 
ness in handling the navel; septic omphalitis; Meckel's diverticulum; 
congenital obliteration of the bile ducts. 

IV. — Hemorrhagic Diseases of the Newly-born 37 

Spontaneous haemorrhage; umbilical haemorrhage; gastro-intestinal 
haemorrhage. 

(vii) 



v iii CONTEXTS. 

CHAPTER PAGE 

V. — Injuries in the New -born 40 

Fractures; obstetrical paralysis. 

VI. — Asphyxia Neonatorum 42 

VII. — Foetal Ichthyosis 4G 

VIII. — Inflammatory and Non-inflammatory Conditions 48 

Icterus neonatorum; sclerema neonatorum; hemoglobinuria neona- 
torum; acute fatty degeneration of the new-born; mastitis neona- 
torum; erysipelas in the new-born; tuberculosis in the new-born; 
peritonitis in the new-born; pemphigus neonatorum. 

IX. — Arnormalities and Congenital Malformations 53 

Angeioma; harelip; cleft palate; tongue-tie; congenital adenoids; 
protrusion of the ears; abnormalities of the air passage; congenital 
stenosis of the larynx; prominent sternum; depressed sternum; 
haematoma of the sterno-mastoid ; cephalhematoma; caput succeda- 
neum; congenital cyst of the kidney; congenital sacral tumor; con- 
genital malformations of the rectum. 

PAET III. 

Feeding in Health and Disease. 

I. — Breast-milk and Wet-nursing 61 

Colostrum; breast-milk; the mammary glands; breast feeding; scanty 
breast-milk requiring mixed feeding; disturbances during breast feed- 
ing; immunity conferred by breast-milk; additional foods during the 
nursing period; diet of a nursing mother; wet-nurse; weaning and 
feeding from one }ear to fifteen months; management of woman's 
nipples; proteid indigestion. 

II. — Cows' Milk 99 

Chemical examination: Fat; sugar; proteids; alkalies; cream, and 
top-milk. 

III. — Home Modification of Milk 139 

Bottle-feeding or hand-feeding; diet for a child from one year to 
fifteen months; diet for a child from eighteen months to three years; 
diet for a child from the third to the tenth year; feeding of delicate 
or sick children; substitute feeding; feeding bottles; nipples; sterili- 
zation; pasteurization; caloric method of infant- feeding; milk 
idiosyncrasies. 

IV. — Laboratory Modification of Milk 173 

V. — Other Substitute Foods 182 

Goat's milk; buttermilk feeding; Bulgarian milk; Lahman's vege- 
table milk; Gaertner mother milk; Backhaus's milk; condensed milk. 

VI. — Proprietary Infant Foods 193 

Nestle's food; Horlick's malted milk; milkine; cereal milk; Warn- 
pole's milk food; Imperial Granum; Eskay's albumenized food; 
Mellin's food; Just's food; peptogenic milk powder. 

VII. — Concentrated Preparations of Albumen 205 

VIII. — Additional Nutrients and Stimulants 209 

IX. — Infants' Weight 216 



CONTENTS. 



ix 



PART [V. 

Diseases of the Mouth, (Esophagus, Stomach, 
Intestines, and Rectum, and Disorders 

Associated with Improper Nutrition. 

CHAPTER PAGE 

I. — Diseases of the Mouth 222 

Stomatitis; stomatitis catarrhalis; stomatitis aphthosa; Bednar's 
aphthae; parasitic stomatitis; croupous stomatitis; syphilitic stoma- 
titis; stomatitis gangrenosa; epithelial desquamation; congenital 
hypertrophy of the tongue; bifid tongue; bifid uvula; glossitis; 
ranula ; alveolar abscess; angina Ludovici. 

II. — Diseases of the (Esophagus 234 

Acute oesophagitis; croupous or diphtheritic oesophagitis; retro- 
esophageal abscess; foreign bodies in the oesophagus. 

III. — Diseases of the Stomach 236 

Acute gastric catarrh ; pyloric obstruction caused by spasm of the 
pylorus; hypertrophic pyloric stenosis; gastro-duodenitis; chronic 
gastritis; acute dilatation of the stomach; gastroptosis; ulcer of 
the stomach; cyclic vomiting; dyspeptic asthma. 

IV. — Diseases of the Intestines 26". 

The intestines; bacteria of the intestines; diarrhoea; ileo-colitis; 
chronic constipation; intestinal colic; acute intestinal indigestion; 
chronic intestinal indigestion; acute milk infection; subacute milk 
infection; appendicitis; pseudo-appendicitis; intussusception; um- 
bilical hernia; worms. 

V. — Diseases of the Rectum 328 

Fissure of the anus; simple catarrhal proctitis; croupous proctitis; 
ulcerative proctitis: haemorrhoids; ischiorectal abscess: prolapsus 
ani : rectal polypi. 

VI. — Disorders Resulting from Improper Nutrition (Faulty Metab- 
olism ) 332 

Faulty metabolism: scurvy; rachitis; athrepsia infantum. 



PART V. 

Diseases of the Heart, Liver, Spleen, Pancreas, 
Peritoneum, and Genito-urinary Tract. 

I. — Introductory 361 

II. — Diseases of the Heart 366 

Reflex symptoms of the heart, tachycardia, bradycardia: pulmonary 
stenosis; persistence of the ductus arteriosus Botalli: endocarditis; 
malignant endocarditis; pericarditis; tuberculosis of the pericar- 
dium ; hydroperi Cardura) ; myocarditis. 



X 



CONTEXTS. 



CHAPTER PAGE 

III. — Diseases of the Liver 381 

Jaundice; acute congestion of the liver; functional disorders of the 
liver; displacement of the liver; descended liver; amyloid degenera- 
tion; fatty liver; cirrhosis; focal necrosis; subphrenic abscess. 

IV. — Diseases of the Spleen and Pancreas 386 

V. — Diseases of the Peritoneum 388 

Acute peritonitis; chronic peritonitis; tuberculous peritonitis; 
ascites. 

VI. — Diseases of the Genital Organs 395 

Hernia; hydrocele; adherent prepuce; phimosis; paraphimosis; 
hypospadias; epispadias; cryptorchidism; orchitis; vulvo-vaginitis; 
simple vaginitis; gonorrhoeal vaginitis; vicarious menstruation; 
menstruation praecox. 

VII. — Diseases of the Kidney and Bladder 405 

Acute nephritis; secondary nephritis; perinephritis; pyelitis; ectopia. 
vesicae congenital is; indicanuria; acetonuria; diacetonuria; pyuria; 
diabetes insipidus; lordotic albuminuria; hematuria ; hemoglo- 
binuria: glycosuria; diabetes mellitus: colicystitis; vesical calculi; 
acute cystitis; chronic cystitis; enuresis. 

PAET VI. 
Diseases of the Eesphutory System. 

I. — Diseases of the Xose and Throat 425 

Acute nasal catarrh; nasopharyngeal catarrh; foreign bodies in the 
nose; tonsillitis; follicular tonsillitis; croupous tonsillitis; ulcero- 
membranous tonsillitis; phlegmonous tonsillitis; chronic hyper- 
trophic tonsillitis; tuberculosis of the tonsils; adenoid vegetation; 
pharyngitis; retropharyngeal abscess: spasmodic laryngitis; foreign 
bodies in the larynx; coughs of reliex origin. 

II. — Diseases of the Bronchi, Lungs, and Pleura 450 

Bronchitis; bronchial asthma; broncho-pneumonia; pulmonary 
gangrene; pleurisy; dry pleurisy; pleurisy with effusion; empyema. 

PAET VII. 

The Infectious Diseases. 

I. — Fever 472 

II. — Influenza 479 

III. — Pertussis (Whooping-cough ) 486 

IV. — Pneumonlv. (Lobar) . Tubercular Pneumonia 497 

V. — Acute Tuberculosis. Chronic Pulmonary Tuberculosis 516 

VI. — Acute Diphtheria. Chronic Diphtheria. Intubation. Tracheo- 
tomy. Diphtheroid. Pseudo-Diphtheria 539 

VII. — Rubella ( German Measles ) 622 

VIII. — Measles (Morbilli, Rubeola) 628 

IX. — Scarlet Fever ( Scarlatina) 643 



CONTENTS. x j 

CHAFTEB PAGE 

X. — Duke's Disease (Fourth Disease) 674 

XI. — Varicella ( Chicken Pox ) , 676 

XI L. — Variola and Vaccination 680 

X 1 1 1. — Typhoid Fever 689 

X IV. — Erysipelas 702 

XV. — Malaria 706 

XVI.— Syphilis 716 



PAET VIII. 

Diseases of the Blood, Glands or Lymph-nodes, 

and Ductless Glands. 

I. — Introductory 726 

II. — Diseases of the Blood 733 

Anaemia; splenic anaemia; secondary anaemia; pernicious anaemia; 
leukaemia ; pseudo-leukaemic anaemia ; chlorosis. 

III. — Acute Rheumatism 740 

Muscular rheumatism; torticollis; purpura; purpura rheumatica ; 
lithaemia; haemophilia. 

IV. — Diseases of the Glands or Lymph Nodes 753 

Status lymphaticus; acute adenitis; chronic adenitis; tubercular 
adenitis; mumps. 

V. — Diseases of the Ductless Glands 760 

Cretinism; exophthalmic goiter; acute thyroiditis; abnormality of the 
thyroid; diseases of the thymus gland; diseases of the adrenal glands; 
Addison's disease. 



PAET IX. 

Diseases of the Xeevous System. 

I. — Fontanel 775 

Percussion of the skull; the brain; reflexes. 

II. — Convulsions 7S1 

Headaches; spasmus nutans; stammering and stuttering; chorea; 
hysteria; multiple neuritis; payor nocturnus; masturbation. 

III. — Tetany 798 

Tetanus; epilepsy; myelitis; spina bifida; spinal paralysis; hydro- 
cephalus; meningocele; encephalocele ; cyclops; porencephaly. 

IV- — Tubercular Meningitis 819 

Cerebro-spinal meningitis; acute pachymeningitis; cerebral paralysis; 
pleuroplegia ; pseudohypertrophic paralysis; cerebral abscess; alalia 
idiopathica ; idiocy and imbecility; infantile amaurotic family idiocy; 
concussion of the brain; insolation. 



xii CONTENTS. 



PAET X. 

Diseases of the Ear, Eye, Skin, and Abnormal 
Growths. 

CHAPTE3 PAGE 

I. — Diseases of the Ear 854 

Acute catarrhal otitis media; mastoid operation on infants and chil- 
dren; foreign bodies in the ear; thrombosis of cerebral sinuses. 

II. — Diseases of the Eye 861 

Acute catarrhal conjunctivitis; pneumococcus ophthalmia; pus infec- 
tion of the conjunctiva; purulent ophthalmia; membranous conjunc- 
tivitis; granular ophthalmia; blepharitis; hordeolum; phlyctenular 
conjunctivitis. 

III. — Diseases of the Skin 869 

Eczema ; e?zema rubrum ; . local erythema ; erythema intertrigo ; 
naevus; tinea tonsurans; verruca; urticaria; impetigo; pediculosis; 
miliaria papulosa; miliaria rubra; sudamina; lentigo; seborrhoea; 
furuncle; chronic pemphigus; burns; symmetrical gangrene; scabies. 

IV. — Abnormal Growths 884 

Spindle-cell sarcoma; carcinoma; angeioma; lipoma; enchondromata ; 
papillomata. 



PAET XI. 

Diseases of the Spine and Joints. 

Diseases of the Sfine and Joints 890 

Pott's disease; flat foot; lateral curvature of the spine; morbus 
coxarius; congenital dislocation of the hip; knee-joint disease; dis- 
eases of the ankle-joint and tarsus; wrist-joint and elbow- joint dis- 
ease; acute arthritis. 



PAET XII. 

Miscellaneous. 

I. — Dietary 905 

II. — The Adulteration of Milk 912 

III. — The Examination of the Gastric Contents 915 

IV.— Urine 917 

V. — Bacteriological Memoranda 928 

VI. — Anaesthetics in Children 930 

YIT. — Disinfection 934 

VIII. — The Administration of Drugs 936 

IX. — Local Remedies 937 

X. — Rectal Medication 939 

XT. — Prescriptions for Various Diseases 941 

Hypodermic medication. 

XII.— Table of Doses 944 



LIST OF ILLUSTRATIONS. 



FIGURE PAGE 

1. A, Tympanic cavity. B, Otic ganglion. C, Tooth. J>, Internal carotid. E, 

Tympanic branch. F, Auriculo-teinporal nerve. (!. Auricular brand, 
of auriculo-teinporal nerve. The dotted line connecting B and G repre- 
sents the inferior dental nerve 6 

2. Two middle lower incisors. Xine to sixteen months 8 

3. Four upper incisors. Xine to sixteen months 8 

4. Two lateral lower incisors and four molars. Thirteen to seventeen months. 8 

5. Four canines. Sixteen to twenty-one months 8 

0. Twenty milk teeth. Twenty-three to thirty-six months 8 

7. Tongue depressor 14 

8. Bath thermometer 18 

9. Proper shaped shoe for infant 20 

10. Schering's formaline lamp 22 

11. Incubator , 25 

12. Feeder for premature infants 29 

13. Funnel and catheter for forced feeding 29 

14. Weight chart 30 

15. Case of omphalocele 34 

16. Appearance of abdomen four weeks after treatment 34 

17. Diagram illustrating effects of persistence of the omphalomesenteric duct, 

and the formation of the so-called diverticulum tumor 34 

18. 19. Ribemont's tube for inflating the lungs 44 

20. A case of angeioma 53 

21. Harelip nipple 54 

22. Congenital cystic kidney 58 

23. Congenital sacral tumor 59 

24. Colostrum corpuscles in a drop of milk Gl 

25. Heeren's Pioscop, for optical milk test 60 

26. Specimen of breast-milk from a young mother. 17 years old 68 

27. Specimen of breast-milk, illustrating very high fat, causing gastric disturb- 

ance 68 

28. Showing a drop of milk under the microscope 75 

29. Drop of breast-milk from a very anaemic woman 75 

30. Holt's milk test set, for testing human milk 76 

31. Breast-milk taken from a wet-nurse during menstruation 85 

32. Pear-shaped breasts, best adapted for nursing 89 

33. Ideal feeding cup 91 

34. Xipple-shield for relief of tender nipples 94 

35. 36. Breast-pump 95 

37. Centrifugal testing machine, for handpower 117 

38. Graduated cream gauge 118 

39. Marc-hand's tube - 118 

40. Feser's lactoscope US 

41 . Cows' milk, showing fat-globules 119 

42. Woodward's burette for estimating proteids 125 

'43. Chapin cream dipper 132 

44. Materna home modifier 150 

45. Mitchell's milk modifying gauge 152 

(xiii) 



XIV 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

46. Author's choice of feeding-bottle 157 

47. Bottle warmer 157 

48. Bottle-brush 158 

49. Antieolic nipple 158 

50. Nipple-sterilizer 159 

51. Arnold steam sterilizer 164 

52. Weight chart of M. L 171 

53. Enterprise juice extractor 211 

54. The Chatillon scale 216 

55. Chart showing gain in weight of baby Robert M. F 218 

56. Chart showing gain in weight of baby J. S 219 

57. Chart showing gain in weight of baby fed on Eskay's food ;fUr third week. 219 

58. Chart showing gain in weight of baby A 220 

59. Chart showing gain in weight of baby D. S 220 

59a. Case of sprue (thrush) due to faulty hygiene of the mouth 224 

60. Case of stomatitis gangrenosa (noma) following scarlet fever 230 

61. Hinged bucket 235 

62. Infant's stomach. Actual size. From a case of malnutrition 240 

63. Infant's stomach. Actual size. Died suddenly from convulsions 240 

64. Infant's stomach. Capacity, 10 ounces. Age of child, eleven months 241 

65. Infant's stomach. Capacity of measurement, 14 ounces 241 

65a. Infantile duodenal bucket with syringe attached, to aspirate bile 249 

6'6. Drawing from a case of acute dilatation of the stomach 254 

67. Transamination of the stomach with the aid of a gastrodiaphane, in a case 

of gastroptosis. ( Colored) 256 

68. a, Normal position of stomach, b, Position of stomach in a case of gas- 

troptosis 257 

69. Bacterium coli commune 269 

70. Bacterium lactis aerogenes 272 

71. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1898, 1899. . . 275 
71a. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1900, 1901. . . 276 
71b. Chart of death-rate from diarrhoea in Manhattan and Bronx, 1902, 1903. . . 277 

72. Bacillary diphtheria of the colon or diphtheritic colitis. (Colored) 278 

73. Croupous enteritis, diphtheritic colitis 279 

74. Dysentery. Baby M., thirteen months old. Seen fourth day after illness. 

Serum injected 280 

75 to 80. Abnormalities of the sigmoid flexure 286 

81. Rubber bulb syringe 287 

82. Irrigator, with tube attached and hard rubber points 288 

83. Soft rubber rectal tube for irrigating the colon 288 

84. A case of acute milk poisoning 300 

85. Exact size of catheter used for irrigating a very young infant 304 

86. Stomach-washing. Introduction of the catheter 306 

87. Stomach-washing. Syphoning off the gastric contents 307 

88. Mechanism of intussusception 320 

90. Umbilical hernia 323 

91. Umbilical hernia truss 323 

92. Case of hydreneephaloid (spurious hydrocephalus) 342 

93. Same child, two years later 342 

94. A case of spurious hydrocephalus, illustrating marked frontal and parietal 

protuberances 343 



LIST OF ILLUSTRATIONS. xv 

FIGURE PAGE 

95 to IKS. [Uustrating rachitic erosions of the permanent teeth ;j45 

!»!). Rachitic ribs 340 

100. Case of rickets, showing enlarged spleen, also pendulous belly 347 

101. Five-weeks-old fracture of the humerus in a rachitic child iy 2 years old. . . 348 

102. Rickets, longitudinal section through ossification junction of upper diaphy- 

seal end of femur 349 

103. A severe type of rickets, with enlargement of both condyles of the femur.. 350 

104. Rickets, showing beaded ribs and an enlarged pendulous belly 352 

105. Rickets, showing beaded ribs 353 

100. Rachitic kyphosis (spine) . Front view 354 

107. Rachitic kyphosis (spine) . Back view, same child 354 

108. Athrepsia infantum 358 

109. Athrepsia infantum 359 

110. Apex beat in a very young infant 362 

111. Apex beat in a child about 6 years old 362 

1 12. Apex beat in a child about 12 years old 362 

113. Irregular pulse, low tension, from a case of mitral regurgitation 363 

114. Natural size of Bowles stethoscope for examining children 364 

115. Convenient stethoscope for children 364 

116. Case of pulmonary stenosis — congenital — blue baby 369^ 

117. Child with persistence of the ductus arteriosus Botalli 371 

118. Case of tubercular peritonitis complicated by tubercular empysema 391 

119. Gonococcus. (Colored) 401 

120. Nephritis complicating diphtheria 407 

121. Case of pyelonephritis _ 413 

122. Extrophy of the bladder, and prolapse of anus 416 

123. Atomizer 426 

124. Lefferts' posterior and anterior nasal syringe 427 

125. Lenox nasal douche 428 

126. Graduated douche, suitable for older children 428 

126a. Angina tonsillaris. ( Colored) 430 

127. Vincent's bacillus found in ulcerative angina 433 

128. Throat spray 434 

129. Throat ice-bag 434 

130. The Baginsky tonsillotome 436 

131. The Mackensie tonsillotome 436 

132. Typical adenoid face in a cretin 439 

133. Digital method of exploring the rhino-pharynx for adenoids 440 

134. Temperature chart from a case of retropharyngeal abscess 444 

135. Oil atomizer 445 

136. Steam atomizer 446 

137. Croup kettle 448 

138. Diplococcus pneumoniae ( pneumococcus ) . (Colored) 457 

139. Purulent (suppurative) bronchitis, peribronchitis, and peribronchial 

broncho-pneumonia in a child fifteen months old 458 

140. Diphtheria (septic) broncho-pneumonia. Louis B., age three years 459 

141. Diagram for pneumonia jacket opened at side 461 

142. Diagram for pneumonia jacket opened at front 461 

143. Fever curve in a case of dry pleurisy 463 

144. Fever curve in a case of pleurisy, with effusion 465 

145. Diagrammatic illustration of heart and lungs, left-sided pleuritic effusion. . 466 



xv i LIST OF ILLUSTRATIONS. 

FIGURE PJLGEL 

146. Illustrating a severe localized right-sided empyema 4fi^ 

147. James's apparatus for expanding the lungs in empyema 470 

14S. Influenza bacilli. ( Colored) 479 

149. Case of influenza pneumonia in a child eight months old 481 

150. Case of influenza pneumonia in a child two years old 483 

151. Focal metastatic hematogenous streptococcus — pneumonia following angina. 

( Colored ) 498 

152. Croupous pneumonia 498 

153. Case of influenza and pneumonia 500 

154. Fever curve in pleuro-pneumonia 501 

155. Case of cerebral pneumonia 502 ji - 

156. Cerebral pneumonia, with high temperature and marked decrease in tem- 

perature after cold baths 504 

157. Lobar pneumonia of a severe type 508 

158. Tubercle bacilli and micrococcus tetragenus (sputum). (Colored) 520 

159. Tuberculosis — horizontal section through lower lobe of right lung of two- 

year-old child 521 

160. Acute pulmonary miliary tuberculosis (cut surface of the lung) 523 

161. Fever curve during the early period of chronic pulmonary tuberculosis 536 

132. Temperature curve during the fifth month 536 

133. Chronic nodular tuberculous broncho-pneumonia 537 

164. Diphtheria or Klebs-Loeffler bacilli; smear preparation from tonsillar de- 

posit. ( Colored) 544 

165. True and false diphtheria 545 

166. Section from an inflamed uvula covered with a stratified fibrinous mem- 

brane, from a case of diphtheritic croup of the pharyngeal organs 547 

167. Case of nasal diphtheria 552 

168. Septic type of diphtheria, complicated by myocarditis 553 

169. Broncho-pneumonia complicating diphtheria 554 

170. Pneumonia complicating diphtheria 559 

171. Temperature chart from a case of diphtheria complicated by broncho-pneu- 

monia (step-ladder type of fever) 560 

172. Temperature chart from a case of diphtheria complicated by lobar pneu- 

monia .-." 561 

173. Temperature chart from a case of diphtheria complicated by otitis and 

meningitis 562 

174. Glass aseptic antitoxin syringe 570 

175. Temperature chart from a case of diphtheria, showing the specific effect of 

antitoxin on the temperature 572 

176. Temperature chart from a case of diphtheria, showing effect of dry antitoxin 571 

177. Introducer with tube attached 584 

178. Introducer with tube and detached obturator 584 

179. Introducer holding foreign body tube 584 

180. Extubator 585 

181. Built-up tubes for granulation tissue 585 

182. Fischer's corrugated rubber tube, to be used for intra-laryngeal medication 

in chronic stenosis (recurring stenosis) 585 

183. The mummy bandage, showing child in proper position for the dorsal method 

of intubation 586 

184. Intubation. First step in the operation 587 

185. Intubation. Second step in the operation 587 



LIST OF [ILLUSTRATIONS. wii 

FIG. PAGE 

ISO. Extubation. First step in the operation 589 

187. Extubation. Second step in the operation 5S9 

188. Chart showing laryngeal diphtheria complicated by broncho-pneumonia.... 591 

189. Garage — method used in forced feeding at Willard Parker Hospital 594 

190. Casselberry method of feeding 595 

191. Temperature chart from a case of diphtheria: croup, intubation 590 

192. Laryngeal diphtheria 004 

193. Diphtheria — laryngeal stenosis requiring intubation Oil 

194. Temperature chart from a case of laryngeal diphtheria 013 

195. Silver trachea cannula used in tracheotomy 010 

196. Hard rubber trachea cannula 010 

197. Temperature chart, case of rubella 625 

198. A case of malignant measles, complicated by diphtheria and ending with 

empyema 635 

199. Temperature chart, case of measles complicated by broncho-pneumonia 636 

200. Temperature chart, case of measles complicated by broncho-pneumonia 637 

201. Desquamation of left side of chest in a ease of scarlet fever 648 

201a. Unusually severe desquamation 649 

202. Septic scarlet fever with myocarditis, suppurative arthritis, double purulent 

otitis, general pyaemia 050 

203. Chart showing temperature and complications in a case of scarlet fever. .. 053 

204. Septic nephritis 657 

205. Drop of urine from a ease of post-scarlatinal nephritis 658 

206. The heart in a case of scarlet fever 659 

207. Post-operative scarlatinoid erythema 662 

208. Coffey's glass apparatus for hypodermic saline injections 666 

209. Temperature chart, scarlet fever treated with antistreptococcus serum.... 669 

210. Method of nasal syringing employed in the scarlet fever ward of the River- 

side Hospital 670 

211. Temperature curve in varicella 077 

212. Erysipelas following varicella . 079 

213. Fatal smallpox in an unvaccinated four-weeks-old infant 0S0 

214. Temperature curve in variola 082 

215. Smallpox in a child that was vaccinated during the incubation period 083 

216. Mild discrete smallpox in an unvaccinated girl 684 

217. Accidental vaccination on the cheek 687 

218. Typhoid infantum in a two-year-old boy 691 

219. Stages in Widal reaction . ' 694 

220. Typhoid fever. Severe hcemorrhages 090 

221. Ectogenous streptococcus infection. (Colored) 702 

222. Fever curve in facial erysipelas 703 

223. Fever curve in phlegmonous erysipelas 704 

224. Malaria plasmodia, tertian type. (Colored) 707 

225. Malaria plasmodia, tropical form. ( Colored ) 707 

226. Tertian fever ( intermittent fever) 70S 

227. Quartan fever (double tertian) 709 

228. -Fstivo-autumnal fever (mild type) 710 

229. Spiroehaete pallida and spirochete refringens from a case of syphilis 718 

230 to 233. Syphilitic teeth ' 722 

233a. Congenital syphilis before injection of salvarsan 723 

233b. Appearance of lesions one week after injection of salvarsan 724 

234. Malignant purpura, complicating nasal diphtheria 748 



xviii LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

235. Case of cervical adenitis in which a. positive von Pirquet reaction appeared. 756 

236, 237, 238. Sporadic cretinism 761 

239, 240, 241. Sporadic cretinism 765 

242 to 249. A case of cretinism 706, 707, 768, 769 

250. Sagittal section of normal head of seven and one-half months' foetus 776 

251. Normal head as seen from above 776 

252. Sagittal section of normal head 776 

253. Sagittal section of head immediately after normal, easy labor 776 

254. 255. Sagittal section of head immediately after labor 777 

256. Sagittal section of head of infant six days old 777 

257. Tetany 798 

258. Case of spina bifida 808 

259. Poliomyelitis 810 

260. Infantile paralysis, with atrophy and impaired growth of the right leg, 

and drop-foot 811 

261. Infantile paralysis, with atrophy of the right leg 811 

262. Infantile paralysis 813 

263. Hydrocephalic calvarinm (or skull-cap), widely gaping fontanels and 

sutures 815 

264. 265. Case of chronic internal hydrocephalus 816 

266. Case of encephalocele 817 

267. Tuberculous spinal meningitis 820 

268. Case of tuberculous meningitis, well marked, ending fatally 822 

269. Anatomical illustration, showing the place best adapted for lumbar punc- 

ture 829 

270. Lumbar puncture needle 829 

271. Lumbar puncture made between fourth and fifth lumbar vertebrae 830 

272. Infantile cerebral paralysis 836 

273. Pseudohypertrophic paralysis 840 

274. 275, 276. A case of pseudohypertrophic paralysis 841 

277. Facial Paralysis following mastoid operation 842 

278. Congenital idiocy 846 

279. 280,281,282. Imbecile (Louie W.) 847, 848 

283. Insolation ( heat stroke ) 852 

284. Complication of scarlet fever seen in my service at Riverside Hospital .... 855 

285. Ear syringe 856 

286. A common type of acute mastoid inflammation following influenza 859 

287. Trachoma, showing round, opaque bodies in upper and lower lids 866 

288. Method of everting eyelid 867 

289. Case of gangrene following lobar pneumonia 882 

290. Spindle-cell sarcoma 885 

291. Anterior view of the tumor 886 

292. Enchondromata involving the thumb and index finger 888 

293. Pott's disease 890 

294. Pott's disease, case of Harry F 895 

295. 296. Schoolgirl, showing lateral curvature of the spine, due to faulty posi- 

tion * 897 

297, 298. Tuberculous coxitis 899 

299. Congenital hip dislocation 900 

300. Tubercular elbow-joint 903 

301. Urino-pyknometer, for estimating the specific gravity of small volumes of 

urine . . . ; 920 

302. The horismascope or albumoscope 922 

303. Gas and ether inhaler 930 



LIST OF PLATES. 



PLATE PAGE 

I. — Severe case of scarlet fever, showing eruption at its height. . .Frontispiece 

II. — The Bynl-Dew method of artificial respiration 42 

III.— Fatal foetal ichthyosis 46 ' 

IV. — A drop of normal breast-milk from primipara 64 

V. — Microscopic appearance of raw starch-granules 128 

VI. — Microscopic appearance of starch-granules, showing the effect of heat. 128 

VII. — Geographical tongue, or epithelial desquamation 232 

VIII. — Infant's stomach, one month old 242 

IX. — Infant's stomach, age seven months 242 

X. — Infant's stomach, age eleven months 242 

XI. — Cestodes (tape-worms) 324 

XII. — Chronic enlarged tonsils. Granular pharyngitis 438 

XIII. — Cutaneous reaction with concentrated and diluted tub?rculin 532 

XIV. — Severe cutaneous reaction. Scrofulous reaction 532 

XV. — A, Common type of diphtheria. B, Septic type of diphtheria. C, 

Hemorrhagic type of diphtheria. 77. Septic type of diphtheria.. 554 

XVI — Morbilliform antitoxin rash 556 i 

XVII. — Forms of tongue in scarlet fever 648 

XVIII. — Vaccinia following vaccination 68S 

XIX. — Iodophilia. Pus reaction of blood 730 

XX. — A, Progressive pernicious anaemia: B, Lienal (splenic) anaemia. C, 

Lienal ( splenic) leukaemia. D, Acute leukaemia 734 

XXI. — Henoch's purpura 750 

XXII.— Front view of the foetal skull 778 

XXIII.— Top view of the foetal skull 778 

XXIV. — Posterior view of the foetal skull 778 

XXV. — 1. Meningococcus or diplococcus intraeellularis. 2. Meningococcus 

intracellularis. 3. Micrococcus catarrhalis 824 

XXVI. — Cerebrospinal meningitis 826 

XXVII. — Cerebrospinal meningitis due to the influenza bacillus 828 

XXVIII. — Intracranial injection in meningitis 832 

XXIX. — Xormal mucous membrane of the middle car in the new-born. In- 
flammation of the mucous membrane of the middle ear. Section 
of the vessel of the mucous membrane containing streptococcus 

pyogenes 854 

XXX. — X-ray of congenital dislocation of hip 000 

(xix) 



LIST OF TABLES. 



TABTE PAGE 

1. Average growth of a child from the first to the twentieth year 5 

2. Dentition 7 

3. Pulse-rate from the first to the fifteenth year 10 

4. Pulse-rate: while asleep; awake, crying 10 

5. Respiration while asleep; awake 11 

6. Percentage of incubator habies saved at various institutions 28 

7. Comparative frequency of spontaneous haemorrhage in various parts of 

the body 37 

8. Properties of human milk, and properties of cows' milk 62-03 

0. Five analyses of human colostrum milk made by Harrington 64 

10. Analysis of the first, second, and third portion of breast-milk 65 

11. Comparative analysis of normal breast-milk 67 

1 1. Five analyses of human milk by Mendel 70 

13. Analyses of a normal, a poor, an overrich. and a bad human breast-milk. . 71 

14. Time for feeding 71 

15. A study of 1000 mothers with reference to their ability to nurse 80 

16. Mortality for England and Wales,. 1890-1894. Mode of feeding 97 

17. Mortality for London. 1S90-1894 93 

18. Deaths due to diarrhoea and mode of feeding. Cameron 98 

19. Two hundred deaths. Their mode of feeding 98 

20. Comparative frequency of tuberculosis in cattle, in the various states 109 

21. Milk preservatives and their chemical action 112 

22. Estimation of fat with Marc-hand's tube 118 

23. Comparative ingredients of woman's milk and cows' milk 120 

24. Comparative ingredients of woman's milk and cows' milk 122 

25. Feeding table. Carpenter 134 

26. Biedert's cream mixtures 134 

27. Xumber of bacteria in unripened and ripened cream 136 

28. General rules for bottle feeding 139 

29. Feeding an infant from one year to fifteen months 152 

30. Feeding from eighteen months to three years 153 

31. Feeding from three years to ten years 154 

32. Results on albumin by heating milk 165 

33. Feeding in milk idiosyncrasy 170 

34. Feeding in milk idiosyncrasy 172 

35. Weight table of a laboratory-fed infant 176 

36. Percentage of acidity and difference in fat of buttermilk and sour milk 

before buttering 1S6 

37. Analysis of milks , 189 

38. Comparative ingredients of condensed milk and woman's milk 192 

39. Xestle's food as compared with woman's milk 196 

40. Horlick's milk as compared with woman's milk 196 

41. Milkine as compared with woman's milk 197 

42. Cereal milk as compared with woman's milk 198 

43. Wampole's milk food as compared with Avoman's milk 199 

(xxi) 



i 



xx ii LIST OF TABLES. 

TABLE PAGE 

44. Imperial granum as compared with woman's milk 199 

45. Eskay's food as compared with woman's milk 201 

46. Mellin's food as compared with woman's milk 201 

47. Percentage of ingredients obtained by various modifications of milk with. 

Mellin's food 202 

48. Humanized milk as compared with woman's milk 203 

49. Composition of infant foods as compared with human milk by Mendel 204 

50. Composition of infant foods as compared with human milk 204 

51. Percentage of alcohol contained in various nutritive tonics by Lederle and 

Deghuee 208 

52. Showing gain in a healthy infant fed at the breast 217 

53. Unorganized ferments present in the body, and their action 233 

54. Population, deaths, and death-rate of children under five years of age, dur- 

ing June, July, and August, for 1891-1893 in (Old) Xew York City. . . 301 

55. Population, deaths, and death-rate of children under five years of age from 

1891-1903 in (Old) Xew York City 302 

56. Differential points between rickets and Potfs disease 355 

57. Weight of the heart 382 

58. Classification of cardiac diseases 365 

59. Differential points between hernia and hydrocele 393 

60. Mortality from infectious diseases of children under two years of age in 

Xew York City 475 

61. Infectious diseases 477 

62. Showing the ratio of mortality from infections diseases of children between 

the ages of two and five in Xew York City 478 

63. Showing ratio of mortality from infectious diseases of children between 

the ages of five and ten in New York City 478 

64. Showing percentage of deaths in children under ten years in Xew York 

City from 1890-1902 ' 478 

65. Deaths from whooping-cough in children under fifteen years in (Old) City 

of Xew York 486 

QQ. Manner of feeding in 59 consecutive cases of tuberculosis among the poor. . 517 

67. Deaths from pulmonary tuberculosis in children under fifteen years of age 

in Xew York City 524 

68. Deaths due to consumption in the United States, in children under fifteen 

years during the census year 1890-1901 525 

69. Comparative death-rate in children under fifteen years due to consumption, 

born of foreign parentage 526 

70. Percentage of deaths per 1000 from consumption in children from one to 

fifteen years of age 526 

71. Deaths from other tubercular diseases in children under fifteen years in 

Xew York City ' 527, 528, 529 

72. Deaths from diphtheria and croup in children under fifteen years (Old) 

X'ew York City 540 

73. Percentage of mortality from diphtheria in different cities in the United 

States 541 

74. Relation between length of the bacillus and its virulence 546 

75. Two hundred and nine cases, showing percentage of cases in which the 

different bacteria were found by culture 548 

76. Antitoxin rashes 555 



LIST OF TABLES. xxiii 

TABLE PAGE 

77. Three hundred and forty-two cases immunized against diphtheria and the 

result 569 

78. Mortality and recovery of diphtheria cases at the Willard Parker Hospital 

of New York City 578 

79. Mortality per cent, and recovery of cases intubated at the Willard Parker 

Hospital of New York City 57!) 

80. Monthly averages of recovery in intubated cases of diphtheria at the 

Willard Parker Hospital of New York City 580 

81. Mortality per cent, of cases intubated at the Municipal Hospital, Philadel- 

phia," 1894-1904 581 

82. Mortality of diphtheria cases treated in the Municipal Hospital, Philadel- 

phia, 1890-1904 582 

83. Mortality and recovery of diphtheria cases intubated at the Boston City 

Hospital, 1889-1904 583 

84. A study of the condition of the upper air passages before and after intuba- 

tion of the larynx. Hospital series 598 

85. A study of the condition of the upper air passages before and after intuba- 

tion of the larynx. Private practice cases 001 

86. Deaths from measles in children under fifteen years in (Old) New York City G29 

87. Five hundred and three cases of measles and complications 634 

88. Three hundred and thirty-three cases of measles showing ear complications. 639 

89. Deaths from scarlet fever in children under fifteen years in (Old) New 

York City 644 

90. Mortality of cases of scarlet fever treated in Riverside Hospital, New York 

City 645 

91. Two thousand six hundred and ninety cases of variola, showing per- 

centage of mortality in the vaccinated and unvaccinated 680 

92. Types of variola 681 

93. Deaths from typhoid fever in children under fifteen years in (Old) New 

Y^ork City 690 

94. A study of the various forms and characteristics of the different malarial 

parasites 713 

95. Differential points between syphilis and tuberculosis 721 

97. Blood count at birth, by various writers 726 

98. Variations in number of white blood-corpuscles found by various writers.. 727 

99. Comparative blood changes in various diseases 729 

100. Length and growth of body in cretinism 763 

101. The association of chorea with rheumatism 788 

102. Differential diagnosis between spinal palsy and acute cerebral palsy 810 

103. Deaths from cerebro-spinal meningitis in children under fifteen years, New 7 

York City 825 

104. Various forms of cerebral paralysis and their anatomical lesions 835 

105. Differential diagnosis between folliculosis of the conjunctiva and trachoma. 865 

106. Whitney's test for sugar in urine 926 

107. Table of doses 944 



PART I. 

THE DEVELOPMENT AND HYGIENE OF THE INFANT. 
DIAGNOSTIC SUGGESTIONS. 



CHAPTER T. 
INFANCY AND CHILDHOOD. 

The New-born Infant. 

There are several anatomical and physiological changes which occur 
when an infant passes from a passive intrauterine to an active extrauterine 
existence. The lungs have had no intrauterine function. They become 
active as soon as the infant makes its first inspiration. The stomach and 
bowels become active the moment the first mouthful of food is swallowed. 
The blood-vessels of the umbilical cord, which have nourished the child 
and connected it with the circulatory system of its mother, rapidly atrophy 
as soon as breathing is established. The following are the most important 
changes that take place during the first month of an infant's life : — 

1. The meconium is expelled. 

2. The umbilical cord separates. 

3. The navel becomes cicatrized. 

4. The epidermis cracks and falls off. 

5. The hair is renewed. 

6. The umbilical vessels are obliterated, and the foramen ovale is closed. 
Infancy. — The term infancy is best applied to that period from the 

end of the first month until all of the milk-teeth have appeared, which is 
about the end of the second year of life. 

There are certain anatomical peculiarities which may be important to 
mention, namely : — 

1. The thymus gland. 

2. The large size of the liver. 

3. The existence of an anterior and posterior fontanel. 

Childhood. — The term childhood is applied to that period from the 
end of the second year to about the sixteenth year. 

Childhood ends when puberty begins. Then follows the stage of adoles- 
cence. 

(i) 



CHAPTEE II. 

THE DEVELOPMENT OF THE VARIOUS SEXSES. 

Mental Facllties/ 

The following is the order in which the various senses appear devel- 
oped : taste, sight, touch. 

Heflex Actions. — Yawning may begin at the end of the first week of 
life. 

Sighing commences in the twenty-eighth week. 

Urine is passed and attention called to it by the infant between the 
thirty-sixth and fortieth weeks. From this time on it is advisable to try to 
train the child to be clean and use a chair. 

Suckling or Nursing. — This seems to be congenitally acquired. Be- 
tween the eighth and tenth months an infant should know enough to prop- 
erly guide a nursing bottle to its mouth. It should also know enough to 
properly inspect its various toys at this age. 

Supporting the Head. — The infant should support its head for a few 
moments in the fourteenth week, and should be able to properly support 
the head about the sixteenth week. 

Sitting usually commences between the seventeenth and twenty-sixth 
weeks. The child should be able to properly support the body between the 
thirty-sixth and fortieth weeks. About the forty-second week the child 
should be strong enough to support its back thoroughly. Commencing with 
the forty-fifth week the sitting position should be permanently established. 

When children can sit up and play they should be placed on the floor, 
having a clean rug under them. Active movements can be suggested by 
rolling a small ball or giving the child some toy to play with. The tendency 
to put everything into the mouth must be considered. Hence, large toys, 
such as hollow rubber balls, are best. Playing with beans, peas, and bullets 
has frequently given many a physician an opportunity to try his skill in 
removing them from such places as the middle ear. the nostril, and most 
frequently the stomach. 

Stamping with the feet in the forty-fourth week. 

The first attempts at walking appear about the forty-first week. ~\YaU-- 
ina unaided is rare before the end of the first vear. Two-fifths of all children 



1 The brain, fontanel, and reflexes of the body are described in detail in Part 
IX, "Diseases of the Brain and Nervous System." 

(2) 



DEVELOPMENT OF THE VARIOUS SENSES. 3 

learn to walk between the fourteenth and fifteenth months. Thus children 
must nol be expected to walk properly until they arc one and a half years 
old. 

Children having suffered with disordered stomach and bowels, whether 
from faulty feeding or inherited disease (syphilis) or other organic dis- 
orders, may, it' urged to walk in this weakened condition, invite deformities, 
such as bow-legs. 

Children will not jump, climb, throw things, or turn unaided before 
they are between two and three years old. 

Infants do not learn to imitate before the twenty-eighth week. 

Laughing begins as early as the eighth, sometimes not before the 
seventeenth, week. An infant will laugh heartily with tears in its eyes 
about the forty-fourth week. The mouth will show an expression the mo- 
ment the infant's attention is attracted, between the third and seventh week. 

Kissing with the lips usually at the fifteenth month. 

Tears, when crying, can be noticed after the tenth week. 

Memory. — The memory of an infant can be noticed sometimes before 
the thirtieth week. 

The taste of milk, the sense of feeling, the sight of the mother, the 
presence of the father or the nurse, are distinctly apparent about this same 
time. An infant will notice the absence of its mother about the fourth 
month, and also notice the difference in the sound of the voice. The memory 
seems to be most acute in the fourth year of life. It is surprising to see 
how much children will remember, and how acute their mental faculties 
will be, in the fourth year of life. 

Voice Sounds. — Children will study the movements of the mouth of 
adults, and will learn to note the difference in sound. They will remember 
the meaning of words, especially when brought into use in connection with 
certain objects or places. Words will be uttered in accordance with no dis- 
tinct rule. This is a peculiar individuality which is difficult to record. 
One child will speak ten words at the age of ten months, and be in a 
normal condition. Another child will speak but six words at the age of 
sixteen months and yet be physically and mentally in a normal condition. 
This shows the marked difference in various children in apparently good 
health. 

Very Late Speaking, Slow Development, Good Prognosis. 1 

The center of speech may be inactive, and show no signs of develop- 
ment until the end of the second year. If the child is otherwise healthy 
no alarm need be felt at this state of affairs. If, however, the child is 
backward in its physical development as well as its mental development, 



x See article on "Alalia Idiopathica," Part IX. 



4 SUDDEX LOSS OF SPEECH. 

then treatment must be sought to remedy this condition. If a child has 
rickets, its soft bones and flabby muscles require restorative treatment. 

Sudden Loss of Speech Due to Paealysis. 

If an infant shows proper development, commences to speak, and for 
no apparent reason stops speaking, the cause of the condition should be 
carefully investigated. For example: A child suffering from a severe 
infectious disease, like diphtheria, may, during convalescence, develop 
paralysis, which might cause the sudden cessation of speech. The neglect 
of treatment at such a time may result in permanent injury to the child. 



CHAPTER III. 
THE DEVELOPMENT OF THE BODY. 

Growth and Height. 

The average height of the new-born male is from 19T/2 to 20 inches 
(about 50 centimeters). In the female from H) 1 /-! to 19% inches (about 
48.5 centimeters). Holt's average is one inch more in both male and 
female children at birth. A child grows most rapidly during its first year. 

Table No. 1. 
Increase during 

First year 5 to 6V 2 inches. 

Second year 2 7 2 to 3 x / 2 inches. 

Third year 2*/, to 2 2 / 3 inches. 

Fourth year about 2 inches. 

Fifth to sixteenth year annual increase from 1V 2 to 2 inches. 

Sixteenth to seventeenth year . 1 7 2 inches. 
Seventeenth to twentieth year . 1 inch yearly. 

Diseases of the bones, rickets, and scrofula retard growth. A child 
should begin to walk at the end of twelve months. If a child, when com- 
mencing to walk, uses chiefly its toes and has a limping gait, more espe- 
cially if symptoms of pain be noticed in one knee, and tenderness be caused 
by handling the limb, commencing hip-joint disease may be inferred. 

Dentition. 

Dentition is regarded by most authors as a physiological process. Teeth 
are developed at birth and grow with the infant until they pierce the gum. 
A series of nervous disorders occur after the fourth month and during the 
eruption of the teeth. Such symptoms are a very warm mouth, red and 
inflamed gums, and an excessive secretion of saliva. Eachitic children and 
those having a highly sensitive nervous system will be very restless at night. 
They will roll the head and frequently cry with pain. A finger will usually 
be found between the gums, and the child will try to bite everything within 
its grasp. These symptoms seem to disappear after the eruption of the 
tooth, so there seems to be some relation between the tooth and the symptoms 
described. Rotch states that in certain infants, during the completion of 
the development of a tooth, symptoms connected with the ear will manifest 
themselves. The symptoms are usually produced by a congestion of the 
blood-vessels of the ear which is accompanied by pain and sometimes results 
in an inflammation. 

(5) 



6 THE DEVELOPMENT OF THE BODY. 

Treatment of Inflamed Gums. — When the gums are tense and inflamed, 
severe nervous manifestations frequently exist. An incision made into the 
gums, deep enough to reach the tooth, has frequently been the means of 
producing relief by local depletion. Relieving the tense gum besides 
abstracting the blood has served me in some cases. The indiscriminate 
lancing of the gums must be warned against. In most cases local applica- 
tion will relieve. The application of a 1 to 5000 solution of adrenalin acts 
very well. It may be repeated every hour. A drop of laudanum on absorb- 
ent cotton placed in the middle ear seems to act well in some instances. 
In rare instances we will be told that a child has had convulsions. I must 
emphatically reiterate that such cerebral or nervous symptoms are apt to 
occur in the sick infant, and will never occur in the healthy infant. 




Fig. 1. — A, tympanic eavity; B, otic ganglion; 0, tooth; D, internal 
carotid; E, tympanic branch; F, auriculotemporal nerve; G, auricular 
branch of auriculotemporal nerve. The dotted line connecting B and C 
represents the inferior dental nerve. (Rotch.) 



The association of bronchitis or diarrhoea must be looked upon as 
entirely independent of dentition. The laity are very willing to ascribe 
most disorders arising at or about the period of dentition as clue to the 
teething. The following case will illustrate how careful one must be not 
to be guided by the statements of irresponsible persons, and diagnose den- 
tition : — 

A child, fifteen months old, was seen by me in consultation. This was a well- 
nourished, breast-fed infant, and had four incisors, two upper and two lower. The 
mother stated that the child had had a cough and fever at and before the appearance 
of each tooth. She was very emphatic in stating that her baby was "teething." 
There were anorexia and slight constipation. A dose of castor-oil was given, but the 
symptoms continued. The child Avas very thirsty and seemed to lose flesh. The 
temperature in the rectum was 103° F., pulse 150, respiration 30. An examination 
of the chest showed moist rales and quite diffuse rhonehi. There were a marked area 
of dullness and bronchial breathing in the upper lobe of the right side. The diag- 
nosis of pneumonia was made. Four or five weeks later I again saw this child. The 



DENTITION. 7 

COUgh still existed, and a suspicion of whooping-cough was expressed. An explora- 
tory puncture showed pus. The diagnosis of empyema was made. The child was 
operated upon and made a brilliant recovery. 

The teeth usually appear, according to Professor Baginsky, between 
the third and tenth months. The usual rule is for normal dentition to begin 
about the seventh or the eighth month. 

In a great variety of children premature teething is recorded; I have 
seen a great many children born with two or more teeth. 

Bachitic children, as a rule, teeth very early or very late. In the large 
children's service with which I have been connected I have observed the 
eruption of teeth many times as early as two or three months in very rickety, 
bottle-fed children. These teeth soon decay, and are then known as carious 
teeth. 

In syphilitic (congenital) children premature dentition is frequently 
seen. 

The first teeth are known as milk-teeth. 

The following table will show the usual rule followed by normal denti- 
tion in the average child : — 

Table No. 2. 

19 | 11 | 13 [ 5 | 3 | 4 | 6 | 14 | 9 | 17 

20 | 12 | 15 | 7 | 1 | 2 | 8 | 16 | 10 | 18 

The milk-teeth are twenty in number ; thus, one and two are the lower 
incisors, usually first teeth ; then follow three and four, upper incisors. 

Normal children usually teeth in pairs, and not singly, whereas rachitic 
children usually have an eruption of single teeth, and distinct backward- 
ness in their appearance. Deciduous teeth, commonly called milk-teeth, 
remain until a child is 6 years old, when the permanent teeth appear. 

Baginsky emphasizes the fact that enough stress is not laid on the 
clinical importance of carious teeth as indicating tuberculosis and scrofulous 
conditions. In the section on treatment of rickets I have mentioned the 
value of a nitrogenous diet, especially proteids (albuminoids), to aid in 
the formation of bony structures. The teeth are also included in this 
category. 

Thus, when such drugs as glycerophosphate of lime or iron and hygienic 
measures are indicated for the treatment of rickets they are of especial 
value when backwardness in teething exists. 

When diarrhoea or cholera infantum cleanses the system and when the 
disease is arrested or well under way, normal physiological conditions, such 
as dentition previously delayed, are vigorously continued. Frequently teeth 
will appear immediately following such an acute disease; thus, an. apparent 
delayed dentition, due to a pathological process, will be attributed by the 
laity to the disease or sickness called teething. 



THE DEVELOPMENT OF THE BODY. 





Fig. 2. — Two Middle Lower In- 
cisors. Three to Ten Months; 
Average, Seven Months. 



Fig. 3. — Four Upper Incisors. Nine 
to Sixteen Months. 




Fig. 4. — Two Lateral Lower Incisors and Four Anterior Molars. 
Thirteen to Seventeen Months. 




Fig. 5. — Four Canines. Sixteen to 
Twenty-one Months. 




Fig. 6.— Twenty Milk Teeth. Twenty- 
three to Thirty-six Months, although the 
Average is Twentv-four to Thirty Months. 



l I am indebted to Dr. Dillon Brown for the illustrations, which have recently 
appeared in "The Nursery." 



CHAPTEE IV. 

DIAGNOSTIC SUGGESTIONS. 1 

It is a very difficult matter to give as distinct clinical pictures of 
children in certain diseases as we can of adults. The following points are 
important enough to be noted : — 

First. — There is an absence of expectoration in respiratory diseases. 
Infants cough and usually swa-low their expectoration. 

Second. — An absence of distinct chills and rigors as seen in adults. 

Third. — The tongue, so valuable in adults as an aid to diagnosis, may 
frequently be overlooked as a symptom of importance in young children. 

Fourth. — Very high temperature and pulse-rate may be associated with 
trivial, just as well as they only too frequently denote serious, conditions. 
A normal temperature is frequently seen in septic diphtheria; Ave must, 
therefore, not judge a case by the temperature alone. 

Fifth. — The great peristaltic activity and the anatomical difference 
in the shape of the stomach at birth render such symptoms as vomiting and 
diarrhoea trivial compared with what such symptoms would denote in an 
older and fully developed child. 

Dr. West ably says: "You cannot question your patient, or, if old 
enough to speak, still, through fear, or from comprehending you But im- 
perfectly, he will probably give you an incorrect reply. You try to gather 
information from the expression of his countenance, but the child is fretful 
and will not bear to be looked at; you endeavor to feel his pulse, and he 
struggles in alarm; you try to auscultate his chest, and he breaks into a 
violent fit of crying." Such teehnical difficulties each medical man must try 
to overcome, and here it is that the ingenuity of the practicing physician is 
brought into play. 

There are a great many important points which have a bearing upon 
the diagnosis and which it is well to formulate : First, try to examine the 
infant when asleep. Xote the color of the face, if flushed or pale; the 
color of the lips, if white or cyanotic : the condition of the skin, if dry or 
moist: if perspiration is confined to the head or forehead, or if it affects 
the whole body. Second, note the frequency and character of respiration, 
if painful or natural ; moaning, twitching, or grinding of teeth ; the action 



1 The Babinski reflex, Kernig's sign, tache cerebrale, and the technique of lumbar 
puncture are described in detail in the chapter on "Meningitis." Part IX. 

(9) 



10 DIAGNOSTIC SUGGESTIONS. 

of the nostrils, if quiet or dilating; the eyes if closed, partly closed, or 
staring. Third, note the condition of the fontanels, if closed or open, if 
pulsating, if distended, full, and bulging, or if sunken. 

The pulse-rate should be noted. In counting the pulse-rate certain 
allowances must be made for excitement. The sudden slamming of a door, 
etc., will startle infants and cause the pulse to increase at times from ten 
to twenty beats. 

The pulse varies in infants from 110 to 150. It may be irregular, con- 
sistently with health. After the seventh year it is found to be quicker in 
the female. It is sometimes slower during sleep. A very slow pulse is not 
always an indication of cerebral disease. 

In a study of over 1000 children in health, the following average table 
of pulse was found (Fischer) : — 

Table No. 3. 

At birth 130 to 140 

First year 1 15 to 130 . 

Second year 100 to 115 

Third year 90 to 100 

Seventh year 86 to 96 

Fourteenth year 84 to 94 

Table No. 4. 

Pulse Rate: 

While Asleep. Awake, Crying. 

Infant ten days old 146 164 

One month old 150 176 

Two months old 120 150 

Three months old 112 148 

Six months old 98 122 

One year old 100 120 

Two years old 98 108 

A diagnosis can frequently be made by the condition of the pulse-rate 
added to the general condition. If an infant is suddenly taken ill with 
fever, with symptoms of nausea and vomiting, a dry coated tongue, and the 
pulse-rate about 130, we may look for an acute gastric fever. Such is 
usually the case if the history points to a diet of cake and pie, or cheese, in 
a very young child. 

If, however, the child is feverish and vomits and the pulse-rate is 
between 70 and 80, then we should suspect tubercular meningitis rather 
than an acute febrile disease. Xote the condition of the child's awakening; 
every young infant in a healthy condition awakens with a smile, does not 
frown, is not peevish. 

Frequently, if the clinical history is looked into, we can learn just 
when the infant first became restless or showed some sign of disturbance. 



TEMPERATURE. 11 

This will usually mark the beginning of an illness, if the same is an acute 
condition. 

The Respirations. — From 1 to 2 years of age a child should breathe 
from 24 to 3G times in a minute. The breathing should be diaphragmatic 
in character; in ordinary breathing there should be no recession of the 
chest walls; this occurs in sobbing or if a mechanical impediment exists 
to the entrance of air into the lungs. 

The number of respirations per minute ranges from 30 to 50; in 
early infancy 39 is the actual average. 

Table No. 5. 

From two months to two years, the average is 35. 
From two years to six years, the average is 18 during sleep, 23 awake. 
From six years to twelve years, the average is 18 during sleep, 23 awake. 
From twelve years to fifteen years, the average is 18 during sleep, 20 awake. 

Temperature. — The normal temperature of the child, taken in the 
rectum, varies between 99%° and 100° F. Fever undoubtedly exists if tem- 
perature over 100° F. is noted. The cause should be searched for. No 
indication is more simple or more valuable than that supplied by the ther- 
mometer. By its aid alone we are often led to suspect the advent of typhoid 
or scarlet fever, or to detect some latent pneumonia, or tubercle produc- 
ing irritation, or some other malady which we had overlooked. It should 
be remembered that rigors do not occur in very young children, but that 
convulsions and delirium correspond in a great measure to rigors and 
headache in an adult. The temperature is an important guide as to the 
condition of an infant. The pulse-rate and the character of the pulse are 
even more important. 

Dr. Finlayson has bestowed much attention on the subject of tempera- 
ture in young children, and his observations go to show : — 

1. That there is a fall of temperature normally in the evening of 1°, 
2°, or even 3° F. 

2. This fall may take place before sleep begins. 

3. It is usually greatest between 7 and 9 p.m. 

4. The minimum is at or before 2 a.m. 

5. After 2 a.m. it again rises, and that independently of food, etc.. 
being taken — rises, in fact, during sleep. 

G. The fluctuations between breakfast and tea are usually trifling. 

7. The rise in a day to 104° or 105° F. precludes typhus and typhoid, 
not scarlatina. 

8. In typhoid a gradual increase for the first four days with morning 
remissions is diagnostic (Wunderlich). 

9. In tubercle the evening temperature is as high or, according to Dr. 
liinger, higher than in the morning. 



12 DIAGNOSTIC SUGGESTIONS. 

Eules to be Observed in Taking Temperature of Infants. 

1. Be sure you have a good thermometer. 

2. Inspect it and see that it is well shaken down to below normal before 
using it. 

3. Anoint it with vaseline or oil. 

4. Always use the rectum for infants. 

5. Eemember that infants always object to interference, hence the 
thermometer should be watched, otherwise an accident may happen. 

6. The best position for the child is to lay it face downward on the 
nurse's lap. 

7. Eemember that impacted faeces in the rectum and fermentative con- 
ditions usually increase the temperature. 

The Eye. — Squinting in acute illness is a grave prognostic; it may 
occur from reflex irritation or from paralysis, or from convulsions, but the 
convulsions may cease and the squint remain for awhile or even perma- 
nently. When strabismus occurs in tubercular meningitis, it is usually a 
fatal sign. 

A small pupil is not so common as a large one; it occurs in active 
congestion, in opium poisoning, and in sleep. It should be remembered 
that the eye is always more or less turned up beneath the upper lid. Large 
pupils, if equal in size, are only of grave import when insensible to light; 
inequality of the pupils coming on in acute illness is a very grave prog- 
nostic. M. Jadelot has noticed that the form of the pupil is irregular in 
children suffering from the intestinal irritation of worms. 

The following aphorisms of Bouchut are of practical value: — 

1. In early childhood there is no relation between the intensity of the 
symptoms and the material lesion. The most intense fever with restless- 
ness, cries, and spasmodic movements, may disappear in twenty-four hours 
without leaving any trace. 

2. Abundant perspiration is not observed in very young children; it 
is entirely replaced by moisture. 

3. Fever always presents considerable remissions in the acute diseases 
of young children. 

4. In the chronic diseases of infancy, fever is almost always inter- 
mittent. 

5. When children are asleep their pulse diminishes from 15 to 20 
beats. The muscular movements which accompany cough, crying, agitation, 
etc., raise the pulse 15, 30, or even 40 pulsations. 

6. The diseases of youth always retard the process of growth. 

It is a good plan to auscultate the chest before resorting to percussion. 
The back of the chest is the most important to auscultate in a sick child. 
If there are no physical signs pointing to bronchitis or pneumonia in the 



THE CRY. 13 

back of the lungs, then it is unlikely that the front of the chest will show 
any signs. To be sure, however, both hack and J' font of chest should he 
examined. 

Dr. Vogel gives a valuable caution, viz., that dullness on the right side 
■posteriorly is a normal physiological condition. Owing to abdominal 
pressure the abdominal organs, and notably the liver (as especially affecting 
the right side), is pressed upward. 

Gestures are often significant. In brain disease the child puts its 
hand to its head, pulls at its hair, rolls its head on the pillow, and beats the 
air. In abdominal disease the legs are drawn up, the face is sunken and 
anxious, and the child picks at the clothes. In urgent dyspnoea it tears 
at its throat or puts its hand in its mouth, especially when false membranes 
are forming, or the tongue is much furred, as in fever, etc. 

The cry varies ; it is labored, as if half suffocated, or as if a door were 
shut between the child and the hearer, in pneumonia and capillary bron- 
chitis ; it is hoarse in croup, brassy and metallic, with crowing inspirations ; 
in cerebral disease, especially in hydrocephalus, it is sharp, shrill, and soli- 
tary, the so-called "cri hydrocephalique," whereas in marasmus and tuber- 
cular peritonitis it is moaning and wailing. Obstinate and long-continued 
crying lasting for hours is referable usually to one of two causes; earache 
or hunger. A louder, shriller cry, also on coughing or produced in moving 
the child, is pleuritic. A cry accompanied with wriggling and writhing and 
preceding defecation is intestinal. M. Billard distinguishes between the 
cry and the return, the cry proper being the expiratory act, while the 
return occurs during inspiration. The cry proper is sonorous and prolonged ; 
the return is shorter and sharper; the return is feeble in young infants, 
but increases in strength as the child grows older. It is the return that 
grows weak or ceases toward the end of all diseases. Moaning is especially 
characteristic of the alimentary canal. 

The Tongue. — The following are the chief indications derived from 
observations of the tongue : 1. A furred tongue with whitish fur scattered 
over it indicates dyspepsia, and intestinal irritation. 2. A red, dry, hot 
tongue points to inflammation of the mouth, stomach, etc. 3. Aphthae often 
result from sheer starvation and neglect. 4. A pale flabby tongue marked 
at the edges with the teeth shows great debility. 5. White fur is generally 
indicative of fever. 6. Yellow fur of liver and stomach derangement of 
long standing. 7. Brown fur of a low typhoid condition. Besides these, 
special conditions, as the "strawberry tongue" of scarlatina, the glazed 
tongue of dyspepsia, etc., will be noted under the special diseases they char- 
acterize. 

The Throat. — No matter what the child suffers with, it is imperative 
to examine the throat. Advantage can be taken of the infant while crying 
to observe the tongue, the teeth, the gums, the mouth in general, and the 



14 



DIAGNOSTIC SUGGESTIONS. 



throat in particular. The neglect of an examination of the throat has fre- 
quently been the means of disseminating diphtheria. Many a child's life 
has been sacrificed by failure to make a minute examination of the throat. 

Sleep. — Healthy infants normally sleep from eighteen to twenty hours 
out of the twenty-four. Thus, if infants are restless and do not sleep, such 
insomnia denotes illness. 

Presuming that we have had an opportunity to examine the infant dur- 
ing sleep, let us then have the child undressed and notice the surface of the 
skin ; it should be mottled, the flesh firm, the skin smooth and elastic to the 
touch, and not flabby ; there should be no impediment to the motion of either 
the arms or legs, they should move freely ; the joints should be noted if they 
are swollen, if large or small ; the epiphyses of the long bones should be care- 
fully noted, and evidences of rickets determined, as this has an important 
bearing: on various infantile diseases. 




Fig. 7. — A Very Convenient Tongue Depressor is the 
One Shown in the Illustration. 



I have previously called attention to the necessity of undressing a child 
for its proper examination. Fever which cannot be explained may have an 
eruption of scarlet fever on the body. This can only be detected by undress- 
ing and examining the infant. 

X-RAY OR EOEXTGEN EAYS. 



The value of the x-rays as a diagnostic aid is beyond question. It is 
especially valuable in painful accidents to the extremities where swelling 
and inflammation prohibit manipulation of the parts. Foreign todies when 
swallowed are easily located with the aid of the fluoroscope. I have fre- 
quently been able to trace coins and buttons that were swallowed, from the 
stomach into the intestines. 



X-RAY EXAMINATION. 



15 



A ease of this kind was referred to me by Dr. L. F. Haas. Two days after 
the coin had been swallowed, the round outline could plainly he seen, located in the 
ascending colon. 

Displacement of the heart toward the right axilla by a malignant 
growth involving the left lung can be very plainly made out with the aid 
of a fluoroscopy An intubation tube that was pushed into the oesophagus 
by an inexperienced operator was located by me in the intestine by this 
means. Experts with the Roentgen tube have frequently located cavities in 
the lungs and a' so effusions in the chest. Carl Beck, of Xew York, recog- 
nized as an expert, was the first to demonstrate gall-stones with the aid of 
the x-rays. 

Difficulty in Making an X-ray Examination in Children. — I have fre- 
quently spent hours trying to get an x-ray picture of a child. The noise 
of the spark and the darkened room seem to frighten very young children. 
If it is vital that an x-ray examination be made or a picture be taken, an 
anaesthetic may be necessary. 

In older children an x-ray examination wall aid in establishing the 
diagnosis in congenital dislocation of the hip-joint. (See illustration in 
chapter on "Congenital Dislocation of the Hip.") 



CHAPTER V. 

GENERAL HYGIENE OF THE INFANT. 

Hygiene of the Mouth and Teeth. 

Mouth. — Care should be bestowed on the mouth and teeth. The new- 
born baby should receive an occasional washing of its mouth with a weak 
Solution of boric acid and water. This should be done very carefully and 
gently, or the delicate floor or roof of the mouth will be denuded of its 
epithelium and invite infection. 

Bednar directed attention to the presence of aphthae due to trauma- 
tism. (See chapter on "Bednar's Aphthae.") 

The Teeth. — When teeth are present they should be kept clean. It is 
especially advisable to have the teeth cleaned with a weak antiseptic solu- 
tion such as lister ine and water once a day. Neglect of the teeth will result 
in caries and foul breath. A dentist should be consulted if there is the 
slightest evidence of decay. The necessity for healthy teeth is very appa- 
rent in infancy and childhood. A practical method of cleaning the teeth 
of children is to use a slice of lemon or lemon juice applied with cotton. 

The Management of the Navel (Umbilicus). 
The Umbilical Cord. 1 

If the child is in a good condition and is not blue (cyanotic), and if 
the pulsations of the umbilical cord have ceased, then the cord can be tied 
about one or two inches from the child's body. If the child is feeble we can 
gain by waiting for a few moments as we admit oxygenated blood through 
the umbilical vessels into the child's body. The point to be remembered 
is "to tie the cord if the pulsations therein have almost ceased." This 
usually takes from two to five minutes. 

Some authors, e.g., Professor Epstein, advise making a gauze pouch 
resembling a small tobacco pouch to tie the cord. This can be easily ster- 
ilized by baking in an oven about thirty or forty minutes. Care must be 
taken that the heat is not too great or the gauze will be burnt. 

Do Not Use Oil or Salves. — When salves or oils are used they exclude 
the air and prevent the drying of the umbilical cord, which is so desirable. 
In order, therefore, to admit a current of air through the gauze to the cord 
nothing greasy should he used. The best thing to use is arrowroot or corn- 
starch or a talcum powder containing 1 per cent, of salicylic acid. 

diseases of the umbilicus — haemorrhages, etc., — are described in Part II. 
(16) 



TI1K FIRST BATH. 17 

The following two prescriptions are recommended as drying pow- 
ders : — 

R Talcum 100 grains. 

Acid salicylic 1 grain. 

Mix and apply thoroughly every morning. 

Ifc Talcum 100 grains. 

Boric acid 1 grain. 

Use as above stated. 

If the child's condition is normal and healthy action takes place, then 
the cord usually falls off in about five to ten days. 

After-treatment. — The after-treatment consists in sprinkling one of 
the above-mentioned drying powders, and covering the region of the um- 
bilicus with several dry layers of plain sterilized gauze, over which an 
abdominal binder should be placed. 

An excellent powder is sold in the shops under the name of Velvet 
Skin Powder. 1 It contains the following ingredients: — 

Boric acid 1 gram. 

Lycopodium 0.5 grain. 

Orris root 7.5 grams. 

Boro-tannate of aluminium 0.25 gram. 

Talcum q. s. ad 100 grams. 

Vernix Caseosa. 

The child at birth is covered with vemix caseosa. It is Nature's 
lubricant to protect the infant from the change of temperature prior to 
and after birth. 

It is advisable to lubricate the body with olive or sweet-oil. This will 
soften and remove the vernix caseosa. This can be continued daily until 
the cord has fallen off. 

The First Bath of the Xew-borx Baby. 

The ease with which an infection can take place through the umbilical 2 
vessels accounts for most authors advising against the first bath being given 
until the umbilical cord has separated from the body. After the cord has 
separated and there is no evidence of inflammation or suppuration in the 
region of the umbilicus, then the first bath may be given. This is usually 
about the end of the first week. 



1 The above powder is made by Palisade Manufacturing Companv, Yonkers, 
X. Y. 

2 For disease of the umbilicus read Part II, Chapter on '"Umbilicus." 

2 



18 GENERAL HYGIENE OF THE INFANT. 



Bathing the Baby. 

The temperature of the bath for a new-born baby should be warmer 
than the baths given as the child's age progresses. It is advisable to bathe 
a new-born baby in water having a temperature between 95° and 100° F. 
To determine the temperature of a bath it is necessary to have a bath ther- 
mometer. One having a wooden casing is preferable. (See Fig. 8.) 

We should never guess at the temperature of a bath. Sometimes a bath 
that feels very hot to a sensitive skin may not be as warm as we imagine; 
hence, the rule should be, "depend on the thermometer." The temperature 
of the bath should be lowered or made cooler as the infant grows older. 

The temperature can be lowered five degrees from month to month until 
the bath is given at a temperature of 75° F. This is a tepid bath which can 
be continued during both winter and summer months for the first year of 
life. 

Additional Cleanliness. — It is self-understood that every infant requires 
additional sponge baths to keep its buttocks and genitals clean, especially 




Fig. 8. — Bath Thermometer. 



so after each bowel movement. If a child is properly washed or sponged 
it is not necessary to overdo the use of soap. 

The Use of Soap. — Excessive use of soap will provoke eczema. Soap 
acts as an irritant to the skin if overused. There are some bland soaps 
which, if used in moderation, will do good; thus, the ordinary olive-oil 
soap, commonly known as castile soap, or the ordinary glycerine soap found 
in drug stores is very good. Medicated soaps are of no value for a new- 
born baby unless some special form of soap is required in a skin disease. 

After the Bath. — The child's body should be thoroughly dried and 
powdered, especially in the folds of the skin between the thighs, in the arm- 
pits, around the neck, the back, and the abdomen. We should use powder 
very liberally, as the dryer the skin is kept, the less chance will there be for 
the development of an eczema. 

Sensitive Skin. — If an infant's skin shows a tendency to be red and 
chafed it is advisable to use no soap at all, but an ordinary bath or an 
oatmeal bath made in the following manner will be found advantageous : — 

Oatmeal Bath. — How to make the hath: Take between two and three 
pounds of good oatmeal, and sew into a bag made of cheesecloth. Place the 
bag with the oatmeal in the infant's bathtub, containing one-half the quan- 
tity of water to be used for the bath. After the bag has soaked for about 



CLOTHING. 19 

one-half hour, add enough water to bathe the child's body therein. The 

duration of the bath shall be about five to ten minutes. After the bath dry 
the body thoroughly and apply the following ointment wherever the skin is 
tender: — 

R Calaminaris 5 parts. 

Zinc ointment 50 parts. 

Apply with a piece of clean gauze over the affected parts. Do not use 
the fingers for applying the salve. 

When to Stop Bathing. — It is advisable not to bathe if an infant has 
an eczema or a very reddened skin, and it is a good rule to follow never to 
bathe if an eruption of the body is present, unless such eruption is due to 
an irritation applied to the skin. Turpentine, mustard, and camphorated 
oil, when rubbed into the skin, will cause an eruption resembling scarlet 
fever. Under such conditions the bath may be used; wdien fever appears 
the bath may be continued, providing there is no eruptive disease like 
measles or scarlet fever, and then even the baths may be given if the attend- 
ing physician so desires. When children have a cough or during catarrhal 
manifestations, it may be advisable in some instances to discontinue the 
bath for a day or two. Great care should be used while bathing a child 
suffering with vulvo-vaginitis to avoid infecting the eyes. 

Clothing. 

In Xew York and similar climates children should be comfortably 
clad. The body should never be overheated. The trouble usually found 
is that children are coddled and their bodies overheated by an excess of 
flannels. I have frequently had occasion to treat eruptions similar to the 
lichen tropicus which was produced by an excessive amount of clothing and 
consequent perspiration. 

The body should be well protected in winter, and very loose, light 
clothes should be worn in summer. jSTo infant should be strapped tightly, 
but due allowance must be made for respiration and for the normal exercise 
of the infant, namely, by permitting freedom of the limbs. Xo pressure 
should be permitted on any portion of the body, so that the circulation is 
not impeded. Displaced organs can result from very tight fitting bands. 

The Feet. — The feet should always be protected. I do not approve of 
hardening infants by exposing their bare legs to the peculiarly changeable 
climate of onr Atlantic coast. I have frequently found digestive disturb- 
ances which could be attributed to cold feet. 

The usual shoe found in the shops for the new-born infant, as well as 
the first walking shoe, are simply ornaments and not practical shoes. It is 
advisable to devote at least enorgh care to have the shoes made on anatomical 



20 GENERAL HYGIEXE OF THE INFANT. 

lines. The accompanying illustration (Fig. 9) shows the proper shape 
for the first walking shoe. 




Fig. 9. — Proper-shaped Shoe for Infant. 

The Abdominal Band. — The belly-band is a source of great anxiety to 
the mother. Its support is valuable for the umbilicus when the child is 
troubled with constipation or diarrhoea. It is a valuable support for the 
abdominal muscles if the child is aifected with whooping-cough. It is not 
necessary to wear the band as. an abdominal support more than three months. 
Delicate infants, premature infants, or those suffering with gastrointes- 
tinal disturbances may require a supporting bandage for a much longer 
time. 

Night Clothing. — Due allowance must be made for seasonal changes, 
so that light clothing should be worn in summer and a heavier set in winter. 
Eestlessness will frequently be induced by having the body too warm. 

The Xursery. 

To develop an infant we require fresh air and sunshine. We must 
only compare a flower deprived of sunlight and air to that which is devel- 
oped under ordinary healthy surroundings. An infant should be given 
the best room in the house, with a southern exposure. The reverse is usually 
found; infants are put into the smallest room, as though they were in the 
wa} r . The nursery should be cheerful and sunny, and have a temperature 
ranging between 66° and 72° F. At night, when the child is well covered, 
the temperature may be lowered to 60° F. without hurting the infant. 

Ventilation. — This is one of the most important matters to be consid- 
ered during the development of the infant. An infant should invariably 
be removed from the room in which it has slept, and the windows of the 
nursery should be opened both top and bottom. After proper ventilation 
the windows are closed and the infant may be brought back again. The 
nursery should be ventilated at least two or three times a day. 

When to Take an Infant Out of Doors. — An infant one month old 
should be taken out into the fresh air in summer, sometimes sooner. It is 
understood that the first few times a child is taken out of doors it should 
be taken into the sun, if possible, for one or two hours. On rainy days or 
when it snows I invariably insist on giving the infant air by throwing 
open the windows and dressing the child with coat and cap as though it 



TI1K NURSEMAID. 



NURSERY. 



21 



were to be taken into the street. This can be done for half an hour in the 
morning and afternoon. 

The Nursemaid. — The selection of a nurse is not an easy matter. That 
it is an important matter we can see when we consider cases of tuberculosis 
and syphilis that have been unquestionably transmitted by the nurse to the 
child. My rule is to exclude a nurse who suffers with catarrh or throat 
trouble. They are a constant menace to a healthy child. Specific rules 
should be given by the family physician to each nurse regarding the feed- 
ing, bathing, aud general hygienic management. I invariably advise against 
nursemaids kissing children on the mouth. They should never be per- 
mitted to sleep in the same bed. I have known more than one case of uro- 
genital discharge transmitted to a female infant in this manner. I prefer 
a nurse between 20 and 40 years of age, one that is quiet, mild mannered, 
and that does not "know everything." Experimental feeding, as is fre- 
quently tried by that miserable creature known as the "experienced nurse," 
is responsible for more rickets and weak children than any other method of 
rearing children. It is the mother's duty to consult the physician at least 
once a month or oftener regarding details of feeding, etc., and it is the 
mother's place to instruct the nurse. A mother who is dependent on a nurse 
will find that fact to be a detriment to her child. 

Method of Heating. — An open-grate fire or a Franklin radiator afford 
the best means of heating. Our city apartments in New York are furnished 
with steam heat, and a great many have gas heating. These latter are the 
worst forms of heating and are responsible for more catarrhal affections of 
the air passages than anything else. I invariably advise the use of a kettle 
with steaming water to add moisture to a room in which a gas stove or steam 
radiator is found. 

The air should be kept as fresh as possible; soiled diapers or soiled 
clothing should never be dried in the nursery. Smoking in the nursery 
should not be permitted, and kitchen odors should not be allowed to reach it. 

Light at Night. — To insure proper repose there should be no light and 
no noise in the nursery. With modern conveniences, such as electricity, a 
small, green, glass bulb can be used when a light is necessary. A wax night 
candle will answer for all purposes at night if electric light cannot be used. 

The Furniture. — The simpler the furniture the better. The ease with 
which infants and children contract measles, scarlet fever, and diphtheria 
shows the necessity for plain furniture and no useless overhangings. If the 
physician will explain to the mother that pathogenic bacteria will remain 
for months in carpets and rugs and tapestries, she will understand why 
simpler means are required. It is advisable, if possible, to have a hard- 
wood floor which may be scrubbed thoroughly. All rugs should be aired 
daily, and it is safer to fumigate the same with formaline when occasion 
requires (see Fig. 10). 



22 GENERAL HYGIENE OF THE INFANT. 

The Bed and Pillow. — A cradle that can be rocked should never be 
used for a child. Xothing worse than a feather bed can be imagined ; still, 
I see them frequently. The best thing for an infant to sleep on is a hair 
mattress, and by all means a hair pillow. 




Fig. 10. — A Very Convenient Formaline 
Lamp is Schering's. 



Proper Training. 



From earliest infancy it is advisable to train the baby. It should be 
given the breast, and after it is through nursing or feeding from the bottle 
it should be laid in the crib. If this habit is commenced early, a regular 
habit of resting can be formed. If, on the other hand, we permit the 
infant to sleep next to its mother's breast, it will get into the habit of being 
fondled to sleep. Bad habits will compel the mother to be a slave to her 
child, and wise is she who will accept the honest, well-meant advice of the 
physician regarding regularity in habits. 

Bowels. — An infant three months old can be put on the commode. The 
best time for the infant's bowels to move is after the morning bottle. In- 
struct the mother to place the child on the chair, and if the bowels do not 
move naturally assist the same by injecting about two ounces of water to 
which a few spoonfuls of glycerine have been added. This will aid in 
directing the infant's attention to its bowels. If the mother will do this 
regularly every morning the infant will gradually learn to know for what 
purpose it is placed on the chair. 

Bladder. — What is possible with the bowels can be accomplished with 
the bladder. If the mother or nurse will place the infant on a vessel every 
three or four hours, the infant will gradually learn to hold its urine until 
such time. The infant should be placed on the vessel immediately on awak- 
ening, be it night or day. Children invariably empty the bladder on 
awakening. 



EXERCISE. 



2:; 



Hygiene of the Nervous System. — To develop an infant's brain the 
nervous system requires quiet but cheerful surroundings. Useless excite- 
ment is harmful. To take an infant and handle it like a toy is wrong. I 
have seen infants taken up from a sound sleep to display the "talent" that 
some one had taught them. Nothing is more harmful than to have the 
mother compel her infant to display various tricks during its feeding. While 
this may be a gratification to the friends, it certainly is detrimental to the 
infant's brain and nervous development. 



Exercise. Gyvixastics. 

The infant's clothing should be loose enough to permit t'ie infant to 
use its arms and legs freely. An infant gets exercise in its bath while 
kicking its legs and moving its arms. A cool sponge bath of the body chills 
the surface and causes the infant to draw long breaths; this expands the 
lungs and is the best form of pulmonary gymnastics. 

Leaving children in .their cribs without proper exercises has been the 
means of producing what some authors term "hospitalism." This is simply 
a wasted marasmic or atrophic condition of infants due to faulty hygiene. 
A child that is six months old should be placed on a large rug and permitted 
to roll or crawl at will. When infants are seven and eight months old, 
and desire to stand, they should be encouraged to do so. This grasping and 
other muscular efforts stimulate the circulation, besides giving tone to the 
muscles. Older children should be permitted to exercise, so that there is a 
symmetrical development of the body. Walking is the best out-of-door 
exercise. Older children should ride a bicycle, or ride horseback, or play 
ball. Swimming is a healthy exercise. Gymnastics, both in and out of 
doors, should always be encouraged. In rainy weather older children should 
have pulley weights, dumb-bells, or rowing machine for house exercise. 
When children do not develop properly and show weakness of their mus- 
cles, passive movements, aided by massage, will be serviceable until the 
child is strong enough to continue its own exercise. Healthy children 
should be encouraged to have out-of-door exercise regardless of the weather. 
It is self-understood that during storms children should be kept indoors. 
It is necessary to regulate the amount of exercise to the strength of the 
child. If fatigue or overexhaustion are brought on by excessive exercise 
it will be found to be just as productive of harm as underexercise. 



PART II. 

ABNORMALITIES AND DISEASES OF THE NEW-BORN. 



CHAPTER I. 



PREMATURE INFANTS. 

An" infant born before 280 days of intrauterine life is called premature. 
Some authors maintain that infants weighing less than 4 pounds should 
be considered premature. If the length of the body is less than 19 inches 
then we may suspect prematurity. The internal organs, especially the lungs, 
not being fully developed, we cannot expect normal functions. A premature 
infant does not cry but whines. There is muscular inertia. The circulation 
is very poor and there is a subnormal temperature ranging between 88° and 
96° F. 

Children born at six and a half months have grown up strong at last, 
although it is not often they survive if born before the seventh month. The 
great need of such a baby is heat, and the maternity hospitals employ an 
apparatus, called a couveuse, brooder, or incubator, especially devised to 
supply it. 

For family use a couveuse may be bought at the instrument makers, or 
hired from some of them. This is perhaps better, as the apparatus is costly. 
With an increased degree of attention we may get along fairly well without 
it. If a premature baby is bathed at all after birth, the temperature of the 
water should be 105° F., and the greatest care should be taken, while drying, 
to see that the child is not chilled. It should be made very warm by swad- 
dling it in raw cotton, head and all, leaving only the face exposed, wrapping 
it about with a blanket, and tying it around with a roller bandage. Hot- 
water bottles should be placed on each side of it as it lies thus wrapped up 
in its bed, and fresh ones substituted frequently. A very .convenient method 
is to place the child in a baby's bathtub half -full of raw cotton, in which a 
number of hot bottles have been concealed. 

The infant's only clothing consists of a diaper and a shirt. The room 
should be kept warm, and especially so when this human bundle is un- 
wrapped for its bath. After bathing it should be rubbed with sweet-oil and 
rolled up again in fresh cotton. Often it is better to omit all bathing, and 
simply rub with the oil. These premature infants lose considerably more 
in proportion to their birth weight than babies at term. This is due to 
(24) 



THE CARE OF PREMATURE INFANTS. 



25 



their immature digestive tract; also to the fact that they are almost always 



it the end of two or three 
have done unusually well. 



intensely jaundiced. They gain very slowly 
weeks they have reached their birth-weight, 

The incubator here 
described (see Fig. 11) is 
the one used at the 
Sloane Maternity Hos- 
pital. There is a great 
variety of these incuba- 
tors, but the one made 
by the Kny-Scheerer 
Company in New York 
City will answer all re- 
quirements. Owing to 
its expense the manufac- 
turers will lend an incu- 
bator for a nominal sum 
per month. 

The apparatus is con- 
structed of steel, with 
glass doors and one glass 
window on the side for 
feeding purposes, etc. 
The heat generated in C 
communicates itself to 
the water-filled tubes E 
on the inside, maintain- 
ing a uniform tempera- 
ture at any desired point 
by means of a spiral- 
thermo - regulator inside 
which is controlled by 
micrometer adjustment 
from outside. The hy- 
grometer records the at- 
mospheric conditions of 
the chamber. The air supplied to the infant is filtered through an absor- 
bent-cotton filter in box A; this air can be taken from the room in which 
the apparatus is placed, or directly from the outside by means of simple 
tubes. The revolving wheel M in chimney indicates the perfect circulation 
of air. B is the gas-burner ; H regulates the gas ; D is the funnel through 
which tank C is filled; L is a hygrometer to indicate atmospheric conditions; 
P is a sliding window used in feeding the infant. 




-Incubator made by the Kny-Scheerer 
Company, New York. 



26 ABNORMALITIES AXD DISEASES OF THE NEWBORN. 

In some of the babies the color is poor from the beginning, and at any 
time they are liable to attacks of cyanosis. For these conditions a little 
slapping to cause a good cry or the administration of oxygen will dissipate 
the blueness. Often a few drops of brandy in water given every two or three 
hours will prevent further trouble. One must be very sure, however, that 
nothing has been aspirated into the larynx (Griffith). 

A great danger in the care of these babies is their susceptibility to 
infections. The incubator itself is a great germ carrier and should be 
regularly disinfected. The weakness of the lungs and gastro-enteric tract 
makes the infant especially vulnerable. Unless the air is filtered, dirt is 
carried in continuously; consequently, the streptococcus, staphylococcus, 
and pneumococcus are always present, seeking an avenue of entrance, 
through the skin in eczematous spots or in areas of irritation, at the navel, 
through the eyes, nose, mouth, larynx, lungs, stomach, and rectum, the 
bacteria can gain admission. To prevent infection the most careful cleans- 
ing is necessary, of both the incubator and the baby. Undoubtedly most of 
the deaths of our cases could be traced to this source. 

A Danger of Incubators. — An infant placed in an incubator was found 
dead one morning, suffocated by vomited milk drawn into the lungs. To 
prevent this catastrophe Wormser suggests that infants should not be re- 
placed in the incubator until a certain interval has elapsed after feeding. 
E. Wormser (Centralblatt f. Gynakologie , Xo. 38). 

Finally, in the carrying out of the above essentials in the proper man- 
agement of the premature infant, we require the most patient and pains- 
taking attention on the part of the nurse, and upon her conscientiousness 
depends the chance of its survival. 

Results. 

The statistics are taken from 2314 births which occurred at the Sloan e 
Maternity Hospital. 

Four hundred and ten of these babies were premature, but of these 74 
were stillbirths, which include macerated foetus and stillborn cases of pla- 
centa praevia, accidental haemorrhage, eclampsia, and the like, leaving 336 
for treatment. 

Among these cases was a set of triplets, and there were 18 pairs of 
twins; 85 were treated as infants at term, and of these 4 died — a mortality 
of 4^ per cent. ; 145 were put in cotton, and of these 12 died — a mor- 
tality of 8 per cent. Some of this class should have been placed in the 
incubator, but for lack of room it was impossible ; 106 were incubator babies. 

These are divided into two classes : — 

1. Those that died within 4 days after birth. 

2. Those that lived longer than 4 days. 

Twentv-nine of the incubator babies died within 4 days. All of these 



THE CARE OF PREMATURE INFANTS. 27 

were more or less asphyxiated at birth; 9 were breech cases, and of these 5 

were difficult extractions; 3 after an accouchement force in placenta prcevia. 
The rest were vertex presentations, and of these 2 were forceps deliveries; 
(i were under 7 months of uterine gestation ; 22 were between 7 and 8 
months, and 1, S 1 ^ months. 

The etiology of the premature labor was an endometritis in 14; syphilis 
in 2: albuminuria in 1; placenta praevia in 3; accidental haemorrhage in 
1 ; persistent vomiting in 1 ; twin in 1 ; violence in 1, and in -1 the labor 
was induced. The largest baby weighed 5% pounds; the smallest 2% 6 
pounds. Only 5 infants lived over 24 hours ; 24 were in sueh poor condi- 
tion at birth that they survived only a few hours. In 16, autopsies were 
held, and in all of these there was marked atelectasis; in 7 there were 
haemorrhages of some degree, either into the brain or into the serous mem- 
branes; in 2 the foramen ovale was still patent. 

Seventy-seven incubator infants survived the first 4 days; 51 were 
children of primipara?, 27 of whom were out of wedlock; 3 infants were 
under I months of gestation ; 8 were over 8 months ; 9 were breech presen- 
tations ; 1 a transverse, and the rest vertices ; 2 were of triplets associated 
with albuminuria; 18 were in twin deliveries associated with albuminuria 
or hydramnios. The cause of the premature labor was endometritis in 27; 
syphilis in -4 ; phthisis in 2 ; albuminuria in T ; accidental haemorrhage in 
1 ; placenta praevia. in 1 ; in 2 the labor was induced for albuminuria and 
eclampsia ; 1 was a Cesarean section ; another an ectopic gestation by a 
laparotomy ; 12 were slightly asphyxiated at birth, 9 moderately so. and 5 
deeply asphyxiated; 2, after one and one-half hours' work of resuscitation, 
were put in the incubator head downward, and their condition was so poor 
that they were not expected to live, but they left the hospital gaining in 
weight; 5 weighed less than 3 pounds; 38 between 3 and -4 pounds; 33 
between 4 and 5 pounds; 1 over 5 pounds; the average weight was 3% 
pounds. During their incubator life 28 had one or more attacks of atelec- 
tasis. All but 10 were more or less jaundiced. The initial loss of the 
infants was from 1 to 17 1 / 4 ounces; the average was 7 ounces. 

These figures are not quite correct, as the babies were weighed at dif- 
ferent intervals, some on the fifth day, some on the seventh day. and some 
not until the fourteenth day. 

The period of loss was from 5 to 22 days ; the average 11 days ; 10 lost 
steadily until death ; 1 baby was in the incubator only 3 days, while another 
lived there 82 days. The average time was 19 days. Some were removed 
early to make room for others who needed the place more urgently. 

Only 3 of the 77 cases vomited. The stools were normal in 32. 

One was discharged from the hospital as early as the eleventh day, 
and others, also, too soon at their mothers' demand. One was 89 days old ; 
the average was 2-4 days. 



28 



ABNORMALITIES AND DISEASES OF THE XEW-BORX. 



In 16, diluted breast-milk was supplemented at times with a mixture 
of cows' milk and water, with Eussian gelatine and lactose. In 10, a 1, 6, 
0.33 1 modification was used. In all the rest diluted breast-milk was relied 
upon. Twenty-seven never nursed at the breast; of these 12 died. A few 
nursed as early as the third or fourth day two or three times daily; others 
not for three weeks, and 1 not till the sixty-eighth day. Of the ?7, 13 died in 
the hospital — a mortality of 16 per cent. The cause of death was atelectasis 
and bronchitis in 7 ; acute asphyxia from a curd in the- lar}-nx in 1 ; syph- 
ilitic pneumonia in 1 ; cerebral haemorrhage in 1 ; gastro-enteritis in 3, 
and a patent foramen ovale and ductus arteriosus in 1. The condition of 
3 was poor at the time of discharge, fair in 21, and very good in 37; 32 
were above their birth-weights, and 57 were gaining in weight. To letters 
written about January 1, 1900, no answer was obtained from 28. Thirteen 
were reported as having died; 1 of these lived 11 months; 1 lived 4 1 /, 
months; 3 lived 2 months; 6 lived 6 weeks; 1 only a month. Five of these 
died at the Nursery and Child's Hospital, and 2 died at Bellevue Hospital. 
They were bottle-fed, and the probable cause of death was gastro-enteritis. 

Twenty-one were found to be alive and doing well. Some had nursed, 
and the others were bottle-fed. The oldest baby was 22 months, and almost 
all were good, healthy children. One baby at 7 months weighed 16 pounds. 
It weighed 4% 6 pounds at birth, and nursed from its mother after leav- 
ing the hospital. The ectopic and the Caesarean babies were in beautiful 
condition. 





Table Xo. 6. 






Incubators. 


Tarnier. 
Per Cent, 


Charles. 
Per Cent. 


Sloane 
Hospital. 
Per Cent. 


At the Sloane Hos- 
pital. Not Counting- 
Those which Died in 
a Few Hours. 
Per Cent. 


Saved at 6 months 

Saved at 6i months 

Saved at 7 months 

Saved at 1\ months. 
Saved at 8 months 


16 
36 
49 

77 
88 


10 
20 
40 
75 


22 
41 
75 
70 


66 
71 

89 
91 



Method of Feeding. 

The size of the child precludes the taking of an ordinary nipple; hence, 
various measures have been tried, the most successful of which has been, 
according to the author's experience, feeding with Dr. Breck's feeder for 
premature infants (see Fig. 12). Feed at intervals of one hour, the quan- 
tity varying with the age of the infant. 



Fat, 1; sugar, 6; proteids, 0.33. 



THE FEEDING of premature infants. 



%) 



A prematurely horn baby is certainly doomed without proper food, 
and there are so many other factors to be considered during its life in an 
incubator, such as ventilation, its bodily warmth and cleanliness, that too 
much stress cannot be laid on the value of its food. Without breast-milk, 
therefore, I feel justified in saving: I have yet to see the premature infant 
that will survive, and hence I advise procuring breast-milk, containing no 
colostrum-corpuscles, hut from a woman having a child anywhere between 
two weeks to several months old, and diluting this breast-milk, as stated 
above, with a solution of milk sugar or cane sugar. 

Voorhees 1 says: "Regarding the care of premature babies in incu- 
bators, we have relied mainly on diluted breast-milk, and have only 
employed diluted cows' milk in weak proportions when it was impossible 




Fig. 12. — Dr. Breck's Feeder for Pre- 
mature Babies. Can be made with a 
medicine dropper to which a nipple is 
attached. 




Fig. 13.— («) Funnel. (6) Rubber 
Catheter, (e) Glass Connecting Tube. 
(d) Rubber Tube and Stopcock. 



to obtain the former. In our opinion our results would have been much 
poorer without the help of mothers' milk." 

In rare instances, when infants are very weak and seem to doze and 
will not swallow, they should be fed with a No. 8 American (Tiemann & 
Co.) rubber catheter attached to a rubber tube about one foot in length 
and ending in a funnel. (See Fig. 13.) 

Very small quantities of food should be used in gavage-feedings of the 



1 Archives of Pediatrics, May, 1900. 



30 



ABNORMALITIES AND DISEASES OF THE XEW-BORN. 



mouth or when feeding through the nose. Xo more than 4 to 6 drachms 
should he used, and thus we can feel our way. It is a good point to remem- 
ber that the pharynx being very sensitive, the irritation of the tube passing 
into the stomach may provoke regurgitation of some of this food, and fre- 
quently vomiting will be produced. 

Baby M., born March 31, 1909, was sent by Dr. I. L. Hill to my service in 
the Babies' Wards of the Sydenham Hospital. The weight at birth was five pounds 
two ounces. The feeding consisted of mother's milk three drachms diluted with 
barley water three drachms. On April 2d. when three days old, the weight was 



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ENHAM HOSPITAL 

WEIGHT CHART Date of ^irihMi^V // 1909. 


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Fig. 14. — Birth: | Placed in Incubator; J Removed from Incubator. 

five pounds. The infant could not retain the diluted human milk, there was con- 
siderable projectile vomiting. Condensed milk was then given. Condensed milk 
1 / 2 drachm to two ounces of sterile water. One-half ounce was given at each feed- 
ing. This food was retained but the infant emaciated and its lowest weight was 
four pounds. Gavage was resorted to at every other feeding. The vomiting became 
less and the weight increased, the infant gaining slowly. The extremities were cold. 
The infant was cyanosed and was placed in an incubator. It then weighed four 
pounds four ounces. As the weight remained stationary for one week, the condensed 
milk feeding was discontinued and two drachms of the following formula were 
given: Cows' milk. 30.0; barley water, 50.0; peptogenic milk powder, Vs measure. 
The infant gained rapidly, vomited less, and slept longer. Whenever possible 
we procured woman's milk and substituted it for the cows' milk feeding. The 
infant remained in the incubator twenty-seven days, and was removed weighing 
six pounds seven ounces. 



THE FEEDING OF PREMATURE INFANTS. 31 

The Stool. — From meconium at birth, the stool gradually become a grass-green, 

jelly-like mass; later it was a yellowish-green, saponified stool. The first three 
weeks the infant was constipated. This constipation later improved so that the 
stool was softer, pasty in consistency, and yellowish or yellowish-green in color. The 
infant grew and developed and was discharged in June, 1909, weighing eleven 
pounds. 

Serum Injections. — The subcutaneous injection of sterile horse serum was com- 
menced with the idea of promoting nutrition. About 15 cubic centimeters were 
injected into the loose cellular tissue of the abdomen, and, when it was found that 
it was completely absorbed, a daily injection of 15 cubic centimeters was ordered. 
Later 30 cubic centimeters w 7 ere injected and absorbed. No febrile reaction fol- 
lowed such injection. Although many dozens of these injections were given, with the 
usual aseptic precautions, not once did an abscess or other sign of infection occur. 

The gradual daily increase in weight was attributed in some measure to this 
mode of treatment. 

Since my last edition appeared, I have had excellent results with 
artificial feeding, having saved five premature infants out of six. The 
feeding was identical with case above described. Another successful pre- 
mature case is described in the article on "Caloric Feeding." 

A close study of the details required in the successful rearing of 
undersized infants shows that the following points are helpful : — 

1. Vomiting, if present after feeding, means longer interval between 
meals. 

2. An undeveloped and weak infant taking but several drachms from 
a medicine dropper will be better fed by gavage. Most of my success has 
been due to gavage at regular intervals night and day. 

3. The temperature of the infant is usually subnormal. In addition 
to placing the infant in an incubator, I have its body well oiled, especially 
the feet, and the infant wrapped in cotton. The heat of the incubator 
produces dryness of the mouth and lips, therefore water is given frequently 
by spoon or medicine dropper. 

4. To aid metabolism and to assist the bowels, an injection of a table- 
spoonful of warm sweet oil into the rectum helps to move the bowels. The 
weight should be taken daily, and it is important to increase the percentage 
composition of the food until the infant gains in weight. 

5. The great danger of exposure prohibits the daily bath, hence the 
infant should be cleansed by inunctions w r ith warm oil. 

The Incubator. — The strict supervision of an incubator demands two 
trained nurses. The heat must be regulated. -The thermometer on the 
inside of the incubator must frequently be observed and the moisture 
properly regulated, so that the air in the incubator is not too dry. 

As a rule, an incubator infant, if otherwise healthy, shows restlessness 
when its feeding time arrives. The infant is taken from the incubator, the 
doors of the incubator are closed to retain the heat, the infant is rapidly 
fed by gavage or the feeder, and returned to the incubator. 



CHAPTER II. 

PROPHYLAXIS AXD TREATMENT OF THE EYES IX THE XEVT-BORX". 

The vaginal discharge of a pregnant woman contains pathogenic bac- 
teria. This frequently gives rise to an infections catarrh in the new-born. 
It is therefore important to treat the eye of the new-born baby with 
extreme care to prevent an infection which can produce serious results. 

Tkeatmext of the Eyes in the New-born. 

Ordinarily the eyes should be washed with a pledget of sterilized cotton 
clipped in plain sterile water or a 2 per cent, boric acid solution. The 
mouth and nose should be similarly treated. All cotton used for the hygiene 
of the mouth, nose, and eyes should be burned immediately after use. 

Crede advises the use of a* 1 per cent, solution of nitrate of silver. 
One drop (no more than one drop) is allowed to drop from a solid glass 
rod or a medicine dropper on the center of the cornea. Its object is to 
prevent the infant from acquiring ophthalmia neonatorum. 

The prophylaxis of blindness is worth studying. The Xew York 
Association for the Blind reports many eases "of needlessly blind victims 
of ophthalmia neonatorum."* The official census of the blind for the 
State of Xew York for 190G gives a total of 62 00, out of which number 
1981 were preventable blindness, most of them caused by ophthalmia 
neonatorum. 

Garrigues 1 states that in lying-in asylums before this treatment was 
adopted, purulent ophthalmia was very prevalent. 

Statistics show that one-half to two-thirds of those affected with 
blindness lost their sight from this cause. 

When the frequency of the gonococcus in the vaginal secretions of 
women delivered in lying-in asylums is considered, then the wisdom of 
prophylaxis cannot be questioned. 

Of late protargol (10 per cent, solution) has been substituted for the 
nitrate of silver solution. It is just as effective and less irritating. 

Solution argyrol (20 per cent.) is very useful in the catarrhal affec- 
tions of infants and children. I have seen very good results during my 
service at the Willard Parker Hospital with the same. 2 



1 Henry J. Garrigiies: "Textbook of Obstetrics/' 1902. 
- See also Part X, "Diseases of the Eye." 

(32) 



CHAPTER III. 
DISEASES AND MALFORMATIONS OF THE UMBILICUS. 



Granuloma. 

A mass of fungus or exuberant granulations is frequently found in 
the umbilicus. Sometimes the granuloma resembles a large red bead. It 
is usually seen after the cord has separated. A discharge usually oozes. 
These granulations bleed very easily. 

Treatment. — The application of a solid stick of nitrate of silver to 
thoroughly destroy the granulations is usually all that is required. If these 
granulations persist then the same can be removed with the aid of a sharp 
curette by simple scraping, after which a dusting powder like europhen 
should be used. 

Diphtheritic Omphalitis. 

The new-born baby is occasionally infected with diphtheria. If there 
is an omphalitis the Klebs-Loeffler infection can easily be transmitted. The 
following case was seen by me in consultation : — 

A child 4 rears old suffered with diphtheria of the upper air passages, which 
finally spread to the larynx, necessitating intubation. This family lived in a 
crowded apartment. The mother gave birth to an infant five days later, and was 
herself infected with diphtheria of the vagina and vulva. Her new-born baby 
was about six days old when I first saw it. The umbilical cord had just sloughed 
away. The region of the umbilicus was highly inflamed and covered with thick 
pseudo-membranes. The child died on the eleventh day, of septicaemia. A culture 
taken showed Klebs-Loeffler bacilli. The physician that attended this family told 
me that the nurse in charge of the older child with laryngeal diphtheria also nursed 
the mother and the new-born baby. He believed that the infection was undoubtedly 
carried by the nurse. 

Treatment. — Locally bichloride of mercury, 1 to 2000, applied con- 
stantly. Internally, antitoxin. (See chapter on "Diphtheria.") A case 
of this kind requires the same vigorous treatment as any other case of 
diphtheria. 

The Daxgers Ixcidext to Carelessxess ix Haxdlixg the Navel. 

If through some accident the ligatures around the umbilical cord 
should slip, and blood oozes from the wound, fatal haemorrhage can result. 
The attention of the physician should at once be directed to this condition. 
This can become a very serious matter if neglected, hence it is of the utmost 
importance to remedy it at once. The neglect of such things, besides the 

(33) 



34 



DISEASES AND MALFORMATIONS OF THE UMBILICUS. 



improper bandaging or uncleanliness in this region, is liable to cause not 
only convulsions, but blood poisoning and death. 




Fig. 15. — Case of Omphalocele admitted to the Babies' Wards of the 
Sydenham Hospital. A semi-globular tumor 4 inches in diameter, and 
2Y 2 inches above level of the body. The stump of the umbilical cord is 
seen on the left side of the tumor. Sterile gauze dressings were applied. 
After several weeks the mass gradually sloughed off and the wound closed. 
( Original. ) 




Fig. 10. — Appearance of abdomen four weeks after treatment, 
was discharged cured when six weeks old. (Original.) 



Case 



Septic Omphalitis. 
An infant was seen by me, through the courtesy of Dr. S. Straus, in 
this city during the summer of 1902. History, as follows : — 

It was the first child born; no previous miscarriage; family history excellent; 
no history of syphilis; labor was easy, and baby was born in natural manner. 
The mother was in excellent health; had milk in both breasts; normal temperature. 
Asepsis was thoroughly carried out. The infant had a temperature of 103° F., in the 
rectum, slight gastroenteric complication, greenish, colicky stools; the umbilicus 
was inflamed and excoriated; slight evidence of pus. 

Diagnosis. — Septic omphalitis due, probably, to infection by the nurse with un- 
clean hands while dressing the umbilicus. 

Treatment. — Strict asepsis to be followed. The umbilicus to be washed with 



CONGENITAL OBLITERATION OF THE BILE DUCTS. 



35 



1 to 2000 bichloride of mercury. Sterile gauze and aristol or some drying powder 
applied. The stomach and bowels were cleansed with calomel, and the infant fed 
every two hours at its mother's breast. The child made an excellent recovery in 
about four or five days. 

Meckel's Diverticulum. 

A condition which ma)' at first simulate umbilical polypus, and for 
which umbilical polypus may be a symptom, is the persistence of a Meckel 
diverticulum. This consists of the persistence of a piece of intestine, 
usually patent, connecting the small intestine with the umbilicus. It rep- 
resents a vitelline duct that failed to atrophy when the placental circulation 
became established, and betrays its presence by an escape of faeces from the 
umbilicus. It is a rare malformation (Botch). 

1. 2. 3. 





r-t 



Fig. 17. — Illustrating Effects of the Persistence of the Omphalomesenteric 
Duct and Formation of the So-called Diverticulum Tumor (Kiesman). 

1. The omphalomesenteric duct shown as an opening: leading: from the umbilicus to the 
ilium. 2. Showing: a small portion of the proximal intestinal wall. This may happen in a 
constipated child, while straining at stool. The same condition may occur during: a par- 
oxysm of whooping-cough. 3= The tumor is much larger, frequently sausag-e-sh aped. It 
is irreducible. 

Congenital Obliteration of the Bile-ducts. 

This condition has been carefully studied by John Thomson, of Edin- 
burgh. He has tabulated his studies in his book on "Congenital Oblitera- 
tion of the Bile-ducts," 1892. 

Etiology. — There can be no doubt that various malformations of the 
liver and bile-ducts do occur which are certainly of this nature. For 
example, congenital a-bsence of the gall-bladder has been frequently de- 
scribed, and some of the cases were due to arrest of development, although 
many were probably of inflammatory origin. Wenzel Gruber has published 
a case in which a forked cystic duct was found, and Konitzky has described 
another in which the common duct had an unusually long and curved 
course, and opened into the middle of the horizontal portion of the duo- 
denum, its lumen being narrowed. 0. Witzel also has published notes of 
an infant born with a large number of congenital abnormalities, in whom, 
in addition to hemicephalus, situs viscerum inversus, six fingers on each 
hand, etc., there was a cystic condition of the liver and complete imper- 
meability of both the cystic and common ducts. Other developmental 
defects have been observed, namely, in HeschPs absence of the bile-ducts in 



36 DISEASES AND MALFORMATIONS OF THE UMBILICUS. 

the liver-tissue, and in Professor Simpson's want of the spigelian and quad- 
rate lobes. 

The frequency with which this exceedingly rare condition affects sev- 
eral members of the same family is very strongly in favor of this view, and, 
indeed, it seems difficult to explain it otherwise. It has been suggested that 
this reappearance of the disease in the same family might be explained by 
supposing a common syphilitic taint. This suggestion, however, cannot be 
accepted, for we never find a tendency for an extremely rare manifestation 
of syphilis to recur four or five times in a family without any of the com- 
mon symptoms of that disease being present at the same time. 

Pathology. — The liver is usually found much enlarged, of a very tough 
consistency — clue to biliary cirrhosis — and of a dark green color, owing to 
the presence of numerous masses of inspissated bile in the small bile-ducts. 
In the great majority of cases there is complete obliteration of some part 
or parts of the hepatic, common or cystic ducts, or of the gall-bladder, 
while with very few exceptions, implication of the blood-vessels or other 
tubes in the neighborhood is conspicuous by its absence. 

Pathology of the Lesion of the Ducts. — The lesion has been ascribed 
to three different morbid processes, either acting separately or in combina- 
tion, namely: — 

1. Peritonitis and its results, acting on the ducts from outside, and 
either compressing them or being a source of inflammatory action, which 
spreads afterward to their walls. 

2. An inflammatory or other lesion of the ducts tliemselves. 

3. An arrest or defect of development. 

And further, various predisposing causes have been described as 
accounting for these morbid processes, namely : — 

1. Congenital syphilis. 

2. Diges-tive disturbance on the part of the parents. 

3. Injuries or exposure to cold, either of the mother or child. 

4. Erysipelas of the child. 

Symptoms. — Such children are jaundiced at birth or they become so 
within the first week or two of life; otherwise they are healthy and well- 
nourished. In some cases there is meconium followed by colorless motions ; 
in others the faeces are devoid of color from the very first. The urine is 
deeply bile-stained. The jaundice is of a dark greenish tinge, and lasts till 
death, and the motions remain colorless. A certain proportion of the 
children die from umbilical haemorrhage within the first fortnight, and, of 
those who survive this period, a large number suffer from spontaneous haem- 
orrhage from other situations. The liver steadily enlarges, and the spleen 
also. After living some months the children become more or less emaciated. 
Spasms often supervene, and death ensues in the end in a state of exhaustion 
from some trifling intercurrent disease. 



CHAPTER J V. 
HEMORRHAGIC DISEASES OF THE NEW-BORN. 

Spontaneous Hemorrhage. 

The occurrence of spontaneous haemorrhages is one of the most char- 
acteristic clinical features in these cases. In the cases collected by Thomson, 
in 21 out of the 50 — that is, in almost half of the cases which lived more 
than a few days — the fact of haemorrhages having occurred from some part 
of the body is noted, and in all probability it may have occurred in some 
of the others also, although not mentioned, as the records of many of them 
are so meager. 

The situations of the haemorrhages mentioned in Thomson's collection 
are as follows : — 

Table No. 7. 

Subcutaneous in 7 of the cases. 

Subconjunctival in 1 of the cases. 

Umbilical in 6 of the cases. 

From nose in 2 of the cases. 

Vomited in 4 of the cases. 

From bowel in 8 of the cases. 

From mouth in 1 of the cases. 

From lung in 1 of the cases. 

. Into gall-bladder in 1 of the cases. 

From leech-bite (excessive) .in 1 of the cases. 

A tendency to bleed is found in many children. In the preceding 
chapter I have described haemorrhage as a symptom of congenital oblitera- 
tion of the bile-ducts. 1 I have also described a very serious haemorrhage in 
a case of congenital syphilis (see chapter on "Syphilis") which ended fatally. 
Direct infection through the umbilical vessels is a frequent cause of pyaemia, 
and this same can result in haemorrhage. 

Etiology. — Ritter 2 studied 190 cases. Of these, 24 were associated with 
sepsis. Kilham and Mercelis 3 describe haemorrhages in 10 cases out of 54. 
It seemed that these were all due to one and the same pyogenic infection. 

Gaertner 4 describes a short bacillus which he isolated from two cases 
resembling the colon bacillus. When the same was injected into the perito- 
neum of animals, a disease was produced accompanied by haemorrhage 

1 Read article on "Haemorrhages in Congenital Obliteration of the Bile-duct," 
page 35. 
* 2 Oest. Jahrbueh fur Pediatrik, 1871, p. 127. 

3 Archives of Pediatrics, March, 1899. 

4 Archiv fur Kinderheilkunde, 1895. 

(37) 



38 HEMORRHAGIC DISEASES OF THE NEW-BORN. 

similar to that seen in the new-born. Holt describes a case in which 
cultures were taken by Dr. J. J. Mapes from which a bacillus resembling 
that described by Gaertner was isolated. 

Pathology. — Small or large extravasations of blood may be found upon 
the various internal organs affected. The brain, the thymus gland, the 
stomach, the bowels, the pericardium, the pleura, or peritoneum may have 
ecchymoses upon their surface. A frequent source of haemorrhage is the 
jDresence of ulcers. Gastric and intestinal ulcers are by no means rare. 

Symptoms.- — The first symptom noticed is the presence of blood. This 
may be present in the vomit, in the stool, or in the urine. There may be 
an oozing beneath the skin or from the umbilicus. The bleeding does not 
amount to a very large quantity. The infant is usually very anaemic. The 
pulse is small and feeble. The body is emaciated. The temperature fluc- 
tuates ; as a rule, it is subnormal, although it may be very high. The course 
of the disease is short ; the bleeding usually ceases in a few days. 

Umbilical Hemorrhage. 

Improper tying of the ligature around the umbilical cord or trau- 
matism frequently causes a slight oozing. These oozings are very easily 
controlled by the application of a proper-fitting ligature. When, however, 
a spontaneous haemorrhage occurs it may be impossible to arrest the same 
with ordinary means. In these cases the haemorrhage occurs without pre- 
vious warning. As a rule, the umbilicus has been perfectly normal for a 
few days prior to this haemorrhage. Some authors state that it may be 
fatal in less than twenty-four hours. 

Gastro-intestixal Hemorrhage (Melena). 

Dark-colored, tarry stools are the usual symptoms of melaena. The 
black stool may also contain clots of blood. A crucial test for the presence 
of blood in examining the faeces for the presence of blood-corpuscles is the 
microscope. Normally meconium does not contain blood. Another symp- 
tom is the vomiting of dark-brown liquids; occasionally bright-red blood 
may be present. 

Haemorrhages of the mouth and nose are generally due to syphilis, 
although ulcerative conditions may cause local haemorrhage. When pem- 
phigus or furunculosis is present, haemorrhages frequently occur. Haemor- 
rhage from the female genital organs may occur as well as from any other 
part of the body. They are usually associated with catarrhal inflammation 
of those parts. « 

Diagnosis. — This is usually very easy, especially if the bleeding is 
superficial. The diagnosis is difficult when an obscure place like the intes- 
tine is the source of the haemorrhage. The microscope will usually aid in 



GASTROINTESTINAL Il.KMORKllAdK. 



39 



establishing a diagnosis of blood in the excreta. When the bleeding is 
confined to the mouth and nose, syphilis should be suspected. 

Prognosis. — A careful prognosis should always be given, although the 
disease is not necessarily fatal. Townsend studied 709 cases and recorded 
a mortality of 79 per cent. 

A male infant, six days old. was seen by me through the courtesy of Dr. A. 
Coldwatcr. The child had vomited several times. The vomit contained blood of a 
bright scarlet color. The stool had been yellowish, but now is black and tarry. 
There was a slight oozing of blood from the umbilicus. When I applied some 
absorbent cotton to the umbilical stump, bright scarlet blood was seen. The 
infant was well nourished and was nursed by its mother. The diagnosis of melaena 
•neonatorum was made by the attending physician and I agreed in the diagnosis. 
The treatment consisted in the application of the solid stick of nitrate of silver 
to the umbilicus, and strict aseptic dressing. The haemorrhages were probably due 
to pyogenic invasion. 

Treatment. — Umbilical haemorrhage can best be controlled, as above 
cited, by the application of a solid stick of nitrate of silver followed by a 
dusting powder such as : — 



R. Europhen, 

Alum usta 

Sig. : Dust over umbilicus. 



, aa 3ij, or 8.0 



For the control of intestinal haemorrhage astringent injections are 
not to be relied upon. The suprarenal extract is a very good haemostatic. 
I have frequently used very small doses of hydrastine hydrochlorate, 1 / 50 
to V 100 grain, three times a day, or 1 / i to x / 2 grain suprarenal extract, 
repeated every hour. 

The injection of 15 cubic centimeters to 30 cubic centimeters of 
sterile horse serum is an excellent haemostatic. In the case of a "bleeder" 
recently seen by me in the Babies' Wards of the Sydenham Hospital, one 
injection of horse serum controlled the haemorrhage, due to a paracentesis 
after all local means failed. 



CHAPTER V. 
INJURIES IX THE NEW-BORN. 

Fractures. 

Traumatism during labor is the cause of most fractures in the new- 
born baby. A predisposition may exist, due to defective ossification. When 
the skeleton is not properly developed, then a separation of the epiphyses of 
the long bones rather than an actual solution of continuity of the diapheses 
occurs (Ballantyne). 

This author also doubts the osteomalacic nature of fractures. Ante- 
natal fragility seems to exist by direct heredity. Griffith reports seventeen 
fractures occurring in one case 1 during the first two years of an infant's 
life. Thus we can see that there must be some other factor at work per- 
mitting recurring fractures, rather than invariably traumatism. 

It is true that syphilis has frequently been given as a possible cause 
for a weak-boned skeleton. 

Brittle bones have been attributed to rickets. Prenatal disease on the 
part of the infant or its mother is frequently the cause of fracture. Linck 2 
describes a case of an infant that was born in little more than one pain. 
In this case there was found over thirty fractures in the limbs and ribs. 

Most of the fractures seen are of the "green-stick" variety. The prog- 
nosis in these cases is usually good, unless some complication appears. 

The following case was seen by me in consultation with Dr. A. S. 
Bienenstock, of New York : — 

An infant two days old had a fracture of the humerus. The seat of the 
fracture was in the center of the bone, and not near the epiphysis. 

Mother's History. — The mother of the infant suffered with diabetes for the 
previous eight years, having between 4 and 4.5 per cent, of sugar. During the 
latter months of pregnancy she was in a subnormal condition. The labor was 
dry, and quite some skill was required to deliver the infant. The mother had no 
breast-milk, so artificial feeding was resorted to. 

As this was in midsummer the infant soon became dyspeptic and later 
developed entero-colitis. At the seat of the fracture callus could be felt several 
days after I first saw this infant. Death resulted from summer complaint. 

Obstetrical Paralysis (Ebb's Paralysis or Birth Palsy). 

This condition may be seen soon after birth, or it may not be noticed 
for several days after that event. It is a peripheral paralysis and usually 

1 American Journal of the Medical Sciences, Chap. CXIII, p. 426, 1897. 
'Arch, of Gvmek.. xxx. 264. 1887. 
(40) 



OBSTETRICAL PARALYSIS. ' 41 

involves the deltoid, biceps, brachialis anticus, supraspinatus, infraspinatus, 
and supinator longus muscles. It may also involve the extensor muscles of 
the wrist. 

Symptoms. — The arm hangs limp at the side of the body. The position 
is governed by gravitation. The forearm is extended and pronated, and the 
wrist and fingers flexed. Movement does not cause pain. The reaction of 
degeneration can be demonstrated when the paralyzed muscles are exam- 
ined with the electric current, Such examinations are very difficult in in- 
fants having a thick layer of fat. At times very powerful currents are 
necessary, thus provoking pain. In making an electrical test, the normal 
arm should always be compared with the affected arm. 

Erb demonstrated the fact that "it is possible by a careful examina- 
tion to find a spot two centimeters above the clavicle, back of the outer edge 
of the sternomastoid muscle, corresponding to the point of emergence of 
the sixth cervical nerve between the scaleni, at which point irritation by 
the faradic current will produce a contraction in the deltoid, biceps, 
brachialis anticus, and supinator longus muscles; and if the irritation be 
increased, the extensors of the wrist will also contract. Pressure upon this 
particular region is often made during delivery, either by the clavicle, or 
by forceps, or by the fingers of the obstetrician. This is more common 
when there is a breech presentation and the after-coming head is extracted 
in the common method. The index and middle fingers of the left hand 
being open like a fork over the shoulders of the child, traction is commonly 
made upon the shoulders, and the pressure of the obstetrician's finger in the 
neck often produces injury of the plexus. In some cases injury of the 
plexus is produced by attempts to bring down the hand or arm in breech 
presentations, or to replace these when the head presents. Forceps appli- 
cations in an awkward position may also produce this injury." 

Prognosis. — This depends on the time when the treatment is com- 
menced. As a rule paralysis of the upper-arm type remains three or four 
years. In a case of mine seen recently the paralysis remained until the 
child was 5 years old. When the faradic current is applied and the muscles 
respond, then the prognosis is good ; if there is no response, a cautious 
prognosis should be given. 

Treatment. — The arm should be supported with a sling. Massage aided 
by a faradic current is sometimes beneficial. In severe cases it is better to 
use the galvanic current, using the mildest current that will produce con- 
traction of the muscles. If the child is old enough to be instructed, gym- 
nastics should be tried at home daily. Strychnine may be given three times 
a dav. 



CHAPTER VI. 
ASPHYXIA NEONATORUM (APPARENT DEATH OF THE NEW-BORN). 

The center and regulator of the respiratory movements is located in 
the medulla oblongata. From it also is sent the motor impulse which gives 
rise to the first act of respiration. 

The activity of this center is believed to be augmented by the condition 
of the venosity of the blood ; therefore, all interruptions to placental respira- 
tion — for instance the premature detachment of that organ or the com- 
pression of the cord — and all obstacles to the introduction of air into the 
trachea, such as mucus or blood, will be attended with violent motor im- 
pulses: first, efforts to breathe, and later, convulsive movements producing 
death (Boisliniere). 

There are two forms of this condition usually observed : first, the 
apoplectic form called by older writers livida, and second, the anaemic form 
called by older writers pallida. In the apoplectic form there is a bluish 
discoloration of the skin, a prominence and injection of the conjunctivae, 
and a swollen state of the face and lips. The cardiac pulsations are gener- 
ally strong, and the cord is distended with blood. In the anaemic form the 
child has a deadly pallor; the lips and fingers are pale, the body limp, and 
muscles relaxed. The heart's action is inaudible, presenting the condition 
known as asystole. Duvergie, in studying the asphyxia of adults, noted that 
when people were removed shortly after an embankment of earth had buried 
them, they presented a turgescence of the face, a violent hue of the skin, and 
frequent and regular pulsations of the heart. 

When they were found some time after an embankment of earth had 
buried them, they presented a deathly pallor of the skin, and the heart sounds 
were usually inaudible or very feeble. Thus it is apparent that the above 
conditions of asphyxia present, first, a mild; and then a severe type. 

Causes. 

The main causes of asphyxia are due to : — 

1. Compression of the cord in a natural way. 

2. Premature detachment of the placenta. 

3. Forced rotation of the head in difficult forceps application or great 
contraction of the uterus in head-last cases, thus rendering the vessels of 
the uterus impermeable to blood and suspending the placental respiration. 
Another cause of asphyxia is shortness of the cord from its encircling the 
neck tightly after the head is born. The child's face in this condition be- 

(42) 



PLATE II 




The Byrd-Dew Method of Artificial Respiration. A, Extension. B, Semi- 
flexion. C, Complete flexion. (Grandin & Jarman.) 



A S PH Y X 1 A X EONATOR UM. 43 

comes turgid and blue, and unless relieved the child will die. The promptest 
treatment consists in cutting- the cord above the child's head and delivering 
the infant's body as quickly as possible. Boisliniere advises the above 
method even at the risk of fracturing a humerus. 



Sign for Distinguishing the Stillborn from the Dead. 

Bedford Brown says that the best means for distinguishing the still- 
born from the dead is to be found in the temperature. If the temperature 
keeps near the normal, we must not cease our efforts at resuscitation, even 
if the complete suspension of cardiac and respiratory action has lasted for 
twenty minutes or more; but if the temperature of the child suddenly falls 
10, 15, or 20 degrees below the normal, then the case is hopeless. Another 
sign is the state of the pupil : in the dead the pupil is widely dilated, in the 
stillborn it is but little, if at all, relaxed (Therap. Gaz., Yol. XXXI, 
Xo. 6). The method consists in injecting into each arm 5 drops of whisky 
with 1 drop of tincture of belladonna. If the infant is only stillborn, 
the nervous and circulatory system respond quickly. If there is no response 
or only a very feeble one, warm sterilized water is injected under the skin 
(a drachm or two) and also about 2 drachms with a drop of aromatic 
spirits of ammonia, into the intestines. After this dry heat is applied. If 
these measures fail to produce a reaction, it is a fair test of the absence of 
vitality. 

Treatment. — If the child presents a livid condition and is apparently 
apoplectic with the cord pulsating strongly, then cut the cord as soon as 
possible and allow at least an ounce of blood to escape. Sometimes it is 
necessary to cut the cord in several places. If bleeding does not ensue rap- 
idly, then the cord should be severed and placed in warm water at a tem- 
perature of 105° to 110° F. This will usually stimulate the flow of blood. 

When the child is born in a pallid condition and feels cold, then the 
cord should not be cut until all pulsations therein have ceased. It is in this 
condition that it will be so important to rapidly cleanse the mouth, nose, 
and larynx of mucus and blood. Some authors advise mouth-to-mouth suc- 
tion or suction made through a soft-rubber catheter placed in the larynx, 
but these are usually preliminary means, and success will only follow me- 
thodical application of artificial respiration. 

Byrd's method is very simple. It can be conducted without rough 
handling, a matter of vital importance. The child's body rests on its back 
and is supported on the palm surfaces of the physician's hands. The physi- 
cian, by elevating and lowering his hands, can produce inspiration and 
expiration in a rapid and efficient manner. This method is well worth 
trying. An important point to remember is to pull the tongue forward ; 
for this purpose an artery clamp will serve in an emergency, if the physician 
does not have Laborde's forceps for traction on the tongue. 



44 



DISEASES OF THE NEW-BORN. 



Laborde advises rhythmical traction upon the tongue eight or ten times 
a minute. This is a valuable method and can be used while the child is 
immersed in hot water. Thus the benefit of the stimulus on the tongue will 
be apparent while the hot bath is used. 

Hypodermics of strychnine, 1 / 100 of a grain, combined with 5 or 10 
minims of whisky, may be indicated. Flushing the colon with a pint or 
more of water, temperature 110° or 115° F., to which a half-drachm of 
alcohol has been added, may also aid in stimulating the circulatory and the 
respiratory tract. It is advisable to persevere for some time with the 
above method of resuscitation, even though we may be successful. It fre- 
quently happens that new-born infants will respond to active treatment and 
show signs of life, but we must continue for some time, or the respirations 

will cease and the 
infant may die. 

A valuable 
means of restoring 
suspended anima- 
tion consists in 
immersing the 
new-born infant, 
first into very 
warm water, and 
then into cold 
water. Alternate 
from hot to cold 
water every ten or 

fifteen seconds. 
Fig. 19. 

Ribemont's Tube for Inflating the Lungs. 





Inflation of the Lungs. 

This method is sometimes useful when other means fail. Some authors 
advise the mouth-to-mouth method. This consists in filling the cheeks with 
fresh air and then blowing the same into the infant's mouth. It can also 
be done by introducing a catheter into the infant's larynx. While the mouth- 
to-mouth method is simpler, it is not always a sure way of inflating the 
lungs. Quite frequently the air will be blown from the mouth, through the 
pharynx, into the stomach. To avoid the latter, the head should be thrown 
backward, and compression made over the epigastrium. If the nose is closed 
air is less likely to enter the stomach. 

Mouth-to-mouth insufflation of air is not devoid of danger. Keich 
reported a case of tuberculous meningitis due to attempts at reanimation 
by a tuberculous midwife. The Eibemont laryngeal tube is much safer. 



ASPHYXIA NEONATORUM. 45 



Introducing a Catheteb into the Labynx. 

A soft flexible catheter is more preferable than a stiff catheter, but this 
requires experience, and is not an easy matter in unskilled hands. 

Ribemont's tube (Figs. 18 and 19) is the best instrument for inflating 
the lungs. It is inserted like an intubation tube. It serves two purposes: — 

1. Forcing air into the lungs. 

2. The aspiration of mucus from the trachea or bronchi. 

Great care should be used with any and all methods. No force is 
necessary. 



CHAPTER VII. 
FOETAL ICHTHYOSIS. 

This condition is described by Ballantyne, Kyber, Wassmuth, and 
Carbone as a skin disease of the foetus most probably developed about the 
fourth month of intrauterine life. It consists of horny epidermic plates 
over the whole surface of the body, separated from each other by fissures 
and furrows, associated with certain deformities of the mouth, nose, eyes, 
ears, and extremities, and leading to the death of the infant very soon after 
birth. 

It is a rare condition, as only 42 cases could be found in the whole 
literature up to the year 1895. For the following case I am indebted to 
Dr. A. S. Daniel :— 

Clinical History. — This case was first seen five hours after birth. The child 
had passed urine and meconium, cried continuously, sleep was impossible. The 
slightest jar of the crib or exposure to the air increased the crying. The respiration 
was irregular, the surface of the body cold. The child swallowed with difficulty 
and was fed with the aid of a medicine dropper. The child died suddenly twenty- 
four hours after birth. The temperature taken soon after birth was 103° F. 

Description of the Child. — There was no resemblance between the child and a 
human being or any living thing. The tongue was the only part of the body that 
seemed capable of motion. The body presents the appearance of having been in an 
integument much too small for the skeleton, and Nature in its growth had so 
stretched the skin that it has the appearance of being torn in some places. Where 
it is torn through, a purple-covered slit appears; where torn partly through, a 
yellowish-colored fissure remains. There is no uniformity of arrangement of the 
fissures. Fewer are found on the back, and those on the extremities are more 
shallow. The color of the fissure, a purplish red, is in marked contrast to the color 
of the skin. In a few places bright blood is found, as if the break were of recent 
origin. The whole body is cold and rigid. The scalp is divided into fissures and 
numerous irregular conical projections, varying in size. A few thin hairs are 
found on the lateral surface of the scalp. The external ears are replaced by conical 
projections. The palpebral fissures are filled with purplish-red masses; deep down 
in the sockets, eyeballs can be distinguished. The nose is flattened and is identified 
by the widely opened nostrils. The mouth is open, showing a non-hypertrophied 
tongue. The lips are of a purplish-red color. The mouth measures 5 centimeters 
in length. Circumference of head, 36.5 centimeters; glabella to occiput, 18.5 
centimeters; ear to ear, 15.5 centimeters. The neck is short. Anteriorly a 
fissure extends from the neck to the umbilicus, 2 centimeters in width. From this 
fissure, ridges of yellow skin and purple fissures extend toward the axillae; they 
are of irregular size and depth. 

The extremities are rigid and in the foetal position. The arms can be raised 
only at right angles with the body. They cannot be extended at the elbow. The 
(46) 



PLATE III 




Fatal Foetal Ichthyosis. Case of Dr. Annie S. Daniel. 



FOETAL [CHTHYOSIS. 17 

hands are thickened and the fingers are rudimentary. The legs arc crossed. The 

motion at the hip and knee joint is very imperfect. The toes are rudimentary. 

The median raphe in the scrotum is faintly marked; testicles are not 
descended. The penis is ••_> centimeter in length. The amis is open. The length 
of the foetus is 42 centimeters, and its weight is 4 pounds 13 ounces. In this case 
it was impossible to find any clinical cause for the disease. 



Of the cause of foetal ichthyosis practically nothing is known. That 
it is not a fatal disease in utero is demonstrated by the fact that only one 
case thus far has been stillborn. 



. CHAPTER VIII. 
INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. 

Icterus Neonatorum. 

This form of icterus is frequently designated as a physiological con- 
dition. It usually begins on the second or third day after birth, and may 
continue for a week or even a month. Henoch reports a case of icterus 
brought to his clinic which lasted five weeks and ended fatally. The ma- 
jority of text-books describe this condition as a mild disease and give a good 
prognosis. There are many theories as to the causes leading up to this 
condition. The haematogenic theory maintains that a disintegration of red 
corpuscles takes place. This liberates the haemoglobin, giving rise to the 
yellowish pigmentation. 

Kacchi, of Naples, disproved the correctness of this theory by a series 
of blood-counts which he reported at the International Medical Congress 
held at Eome in 1895. 

"We can scarcely believe that the red corpuscles simply go to pieces in 
the blood, and that the products of such disintegration, floating freely about 
or temporarily lodged in the tissues, give rise to the yellow color. It is far 
more in accordance with the workings of the living organism to suppose 
that the disintegration takes place in some organ, e.g., liver or spleen, and 
if the products thereof are floating about, it is after passing such organ 
and on their way to final elimination." 

Infant F. J. was seen by me when three days old. Had greenish stools con- 
taining mucus, and appeared colicky and cried considerably. No vomiting. There 
was a universal yellowish pigment of the body; jaundice well marked; gums were 
yellowish; conjunctival mucous membrane showed yellowish pigmentation. The 
umbilicus was somewhat excoriated and moist from the presence of pus. The 
diagnosis made was septic omphalitis, resulting in hematogenic jaundice. Very 
small doses of calomel, y 10 grain, several times a day, were ordered; also colon 
irrigations with chamomile tea. The infant was nursed by its mother. Aseptic 
treatment of the umbilicus with sterile gauze, cleansing with bichloride, and then 
dusting the parts with talcum salicylicum quickly healed the inflammatory con- 
dition. The infant recovered in about one week, showing no sign of its previous 
jaundice. 

The following case is noteworthy owing to its rarity : — 

An infant was born of apparently healthy parents. Dr. Mehrenlander, the 
physician in attendance, stated that there was nothing abnormal at the time of 
birth. The infant weighed about seven pounds. It was the fourth child. Three 
children of this same family had previously died on the third day after birth. They 

(48) 



SCLEREMA NEONATORUM. 49 

were to all appearances healthy, but were jaundiced. Nothing was noticeable with 
them, excepting the yellow pigmentation of the skin. The child died before I ar- 
rived at the bedside. It was three daya old. The skin then presented a deep yellow- 
Lsh-green pigmentation, more marked on the abdomen. The conjunctival mucous 
membrane was deeply pigmented. There was no inflammatory condition noticeable 
in the region of the umbilicus. The cord was dressed with aseptic gauze, and no 
infection was suspected from this channel. The attending physician suspected 
syphilis in the father. There were no other symptoms. Neither vomiting nor 
diarrhoea. A stool passed before the infant died, which looked like meconium. 

An interesting point about the case is that this was the fourth child in that 
family which died of icterus neonatorum a few days after birth. The child died 
without any apparent suffering, showing no symptoms of illness. The temperature 
when taken was normal. 

Zweifel describes a series of cases of icterus resulting from the effects 
of chloroform passing through the placenta. The writer has noted the asso- 
ciation of icterus neonatorum in a large number of children born after a 
severe labor, requiring prolonged chloroform narcosis. This may have been 
accidental, yet it is worth noting. 

James D. Yoorhees, in responding to my question concerning the asso- 
ciation of chloroform anaesthesia and icterus at the Sloane Maternity Hos- 
pital, states that "all women receive chloroform at said hospital, and about 
33 per cent, of the infants born are jaundiced. All premature infants 
also are jaundiced." 

Sclerema Xeoxatorum. 

This disease is characterized by a hardening or thickening of the skin 
and the subcutaneous cellular tissue. The pathological lesions have been 
carefully studied by Xorthrup. His case was a foundling born amid insani- 
tary surroundings. "When five days old the legs were swollen and the feet 
as hard as a board. 

The swelling spread upward, involving every part of the body. The 
temperature in the rectum was 35° C. (95° F.). The infant died on the 
ninth day. The body felt as though it were frozen. Osier also describes 
this condition in this countrv. 

Symptoms. — An cedema-like swelling, very cold to the touch, and very 
hard on palpation, involving circumscribed areas, appears soon after birth. 
I have seen sclerema spread from the shoulders to the trunk and arms. 

The infant appears very sick. The temperature is subnormal, and 
recovery is rare. 

Was called to see an infant five days old. Found the trunk swollen, the hands 
and feet cold, and the temperature in rectum subnormal. The infant refused the 
breast and had no strength. Brandy and water were prescribed. Mustard foot-bath 
ordered, and one pint of warm saline solution injected into the colon. There was no 
nausea or vomiting. No retention of urine. Sclerema neonatorum was diagnosed. 
The swelling spread, involving the legs and arms, until the whole body, including the 

4 



50 INFLAMMATORY AND NON-INFLAMMATORY CONDITIONS. 

face, was puffed and hard. The infant could no longer open its eyes and died on 
the ninth day in convulsions. 

HEMOGLOBINURIA NEONATORUM (WiNCKEL's DISEASE) . 

Considerable has been written upon this obscure condition which is very 
rarely met with in the new-born baby. As a rule this condition is seen as 
an epidemic in a maternity hospital. Winckel reports nineteen deaths out 
of twenty-three cases attacked. 

Pathology. — Haemorrhages are found in various organs. The lungs are 
black. The bladder, the spinal canal, the liver, and the spleen all show 
darkened secretions. The kidneys are dark colored. All observers state 
that the umbilical vessels are not involved. 

Symptoms. — The skin of the body has a peculiar icteric or bronzed 
appearance. The palms of the hands and soles of the feet have a bluish 
or purplish color. The conjunctiva has an icteric appearance. The stool 
is blackish or greenish. The urine is dark and contains blood; it is thick 
and sometimes resembles syrup. There is no fever. The pulse is very rapid. 
Convulsions and squinting are usually seen. There is a rapid diminution in 
the blood cells, from 5,700,000 one day to 3,400,000 on the third day. 

These cases end fatally as a rule. 

Acute Fatty Degeneration' of the New-born (Buhi/s Disease). 

When an infant is born in an asphyxiated condition and there is asso- 
ciated umbilical haemorrhage, then an infection of pathogenic bacteria may 
take place. In some respects this disease resembles Winckel's disease. In 
both we have haemorrhages as well as fatty degeneration of the internal 
organs. The symptoms are a bleeding from the stomach and bowels, asso- 
ciated with jaundice. In Buhl's disease we have bleeding from the um- 
bilicus. 

Mastitis Neonatorum. 

The new-born infant frequently secretes a fluid in the mammae. Fe- 
males, both human and animal, occasionally secrete milk without having 
been previously pregnant. With regard to the milk secreted by infants, 
there is some doubt about its real nature. Kollicker does not view it as a 
true milk, but considers its appearance connected with the formation of 
the mammary glands. This secretion is also known as witch's milk. 

Sinety, on the other hand, upon anatomical grounds, considers it a 
true lacteal secretion. It probably is a sort of imperfect milk, loaded with 
leucocytes, and this is the more likely as Yollard 1 notices that it frequently 
ends in abscess. 



l "Traite des Maladies des Enfants Nouveau-nes," third edition, 1837, p. 717. 



ERYSIPELAS IN THE NEW-BORN. 51 

Schlossberger gives an imperfect quantitative analysis of a sample of 
milk obtained by squeezing the breasts of a new-born infant, a male. In 
the course of a few days about a drachm was obtained. The following was 
the result of the analysis : — 

Water 9&75 

Fat 0.82 

Ash 0.05 

Casein, sugar, and extractives 2.83 

Sugar-reaction strong 

The most complete analysis w r e possess of such milk is by von Gesner : — 

Milk-fat 1.456 

Casein 0.557 

Albumin 0.490 

Milk-sugar 0.950 

Ash 0.82G 

Water 95.705 

Total solids 4.295 

I was called to see a female infant six days old. The mother told me that the 
breasts were swollen and contained milk. The same could be expressed by gentle 
stroking of the mammae. The treatment consisted of the application of an ice-bag 
and inunctions of: — 

Ifc Ung. ext. belladonna 2 drachms 

Ung. hydrarg. cin 1 drachm 

Cold cream 1 ounce 

M. Apply on linen with tight compresses. 

After several days the breast dried and the swelling disappeared. 

Another infant, three weeks old, was seen by me recently, in consultation. The 
mother was delivered by a midwife, and her condition as well as that of the infant 
was apparently normal. The infant's breasts, when seven days old, appeared tender 
and swollen, and the mother was advised to poultice them with flaxseed. This she 
did, and in addition squeezed the secretion from the infant's breasts. This trauma- 
tism caused irritation, inflammation, and finally the formation of an abscess. An 
incision was made, the pus evacuated, and the wound healed kindly. 

It is important to remember that the lacteal secretion in an infant's 
breast is a physiological condition, and if undisturbed will be absorbed 
gradually. 

1 Erysipelas in the New-born. 

When this disease occurs in the new-born, and the mother has a septic 
peritonitis or other infectious disease, the infant should be immediately 
isolated from the mother. The symptoms are the same as those seen in 
erysipelas of older children, although vomiting and symptoms of general 
sepsis most often accompany this condition. The fontanel is depressed. 



52 INFLAMMATORY AND XOX-IXFLAMMATORY CONDITIONS. 

Prognosis. — The prognosis is usually very grave, especially so if the 
infant must he removed from its mother's breast. 

Treatment. — The strictest antisepsis must he used. An infant should 
be placed under the care of a trained nurse, and all instructions in regard 
to the hygiene of the infant must he strictly carried out. The general plan 
of treatment is the same as that outlined in the chapter on "Erysipelas/' 
page 705. 

Tuberculosis in the New-born. 

The transmission of tuberculosis from the mother to the new-born 
is extremely rare. Cases are on record in which the tubercle bacilli were 
transmitted from the mother to the infant. An occasional transmission of 
tuberculosis takes place through the placenta. The reason for the infre- 
quency of this occurrence is that the blood of a tuberculous patient rarely 
contains tubercle bacilli. Sehmorl and Birch-Hirschfeld believe that ma- 
ternal tuberculosis can be transmitted, but not before the end of the fifth 
month of pregnancy, and that the placenta is always tuberculous when the 
foetus is infected. (For further details see chapter on "Tuberculosis/') 

Peritonitis in the Xew-borx. 

In the chapter on "Omphalitis" I have described a case of septic infec- 
tion seen in consultation practice. The case recovered. At times the in- 
flammatory condition will extend from the umbilicus to the peritoneum, and 
thus a septic peritonitis results. 

Bacteriology. — In such pyogenic infections the streptococcus can be 
found. The bacteria gain entrance directly through the umbilical vessels. 

Pathology. — The same lesions affecting the serous membrane, as the 
pleura and the pericardium, are found in the peritoneum. Adhesions fre- 
quently remain. 

The symptoms, prognosis, and treatment are described in the article 
on "Acute General Peritonitis," Part V. 

Pemphigus Neonatorum. 1 

This condition is seen occasionally in the new-born infant. It consists 
of blebs which contain yellow serum. In size they vary from a pea to that 
of a small bean. When these rupture they are replaced by superficial ulcers 
covered with a thin black crust. Sometimes a violet stain is left, which 
may last for some time. The duration of each bulla is about one week. 
The location of the eruption is on the palms of the hands and the soles of 
the feet. Some authors regard pemphigus as a form of infantile syphilis. 
The cases seen by me have invariably occurred in poorly nourished children 
such as we find in athrepsia (marasmus). 



See article on "Chronic Pemphigus." 



CHAPTER IX. 

ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

Angeioma. 

Circumscribed dilatations of the blood-vessels or capillaries are occa- 
sionally seen in the new-born baby. Spongy tumors consisting of tortuous 
blood-vessels of a bluish-red color are usually seen. These tumors are filled 
with blood and grow very rapidly. In a case seen by me (see Fig. 20) the 
mass was adherent to the forehead and completely obliterated the sight of 
the left eye. This condition is one that can easily be remedied with prompt 
surgical treatment. Some cases will, if neglected, ultimately result in 
sarcomatous degeneration. 

Treatment. — Injections into the mass of a 5 per cent, nitrate of silver 
solution, or destroying the mass with a galvanocautery, chromic acid, or 




Fig. 20. — Infant ten months old. From my children's service at the 
German Poliklinik. The mass of bluish, tortuous vessels interfered with 
the eyesight. Bleeding was very easily provoked. Surgical treatment is 
the only means of eradicating the mass. (Original.) 

(53) 



54 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

nitric acid are most generally used. A good plan is to first apply pure 
carbolic acid, after which the fuming nitric acid should be used. This 
latter method is painless and effective. 

Harelip. 

This congenital deformity is frequently seen in children. Sometimes 
it is simply "a slight indentation in the lip, or the fissure may extend to 
the nostril." The treatment is surgical. 




Fig. 21. — Harelip Nipple. 1 

Cleft Palate. 

This abnormality is frequently seen in children. While the soft palate 
only may be affected, it not infrequently happens that the fissure extends 
through the hard palate, thus causing a wide gap in the roof of the mouth. 

Feeding Children Afflicted with Cleft Palate. — An infant born with 
cleft palate has a greater struggle for existence than a child born healthy, 
without this deformity. It is advisable to give the best possible food, and, 
therefore, breast-milk only should be used. The milk should be drawn from 
a woman's breast by means of a breast-pump, as described in the section on 
"Specimen of Breast-milk for Chemical Examination." 

An artificial nipple should be attached to the feeding-bottle, and to the 
former should be attached a flap of India rubber so made that it fits the 
roof of the mouth. The pressure of the nipple against the piece of rubber, 
when in position, converts it into an artificial palate-piece, and prevents 
the escape of the milk into the nose during the effort of swallowing. This 
shield is chosen to avoid permitting curdled milk to pass into the recesses 
of the turbinated bones and to cause aphthous patches. (See Fig. 21.) 

It is advisable to operate on an infant for this deformity between the 
third and sixth months of its life, if sufficient progress in its development 
will warrant it. 

When the above method of feeding is not satisfactory and the child 
shows evidences of starvation, then we must resort to gavage. (See chapter 
on "Gavage.") 

Our aim should be to build up the infant from its birth, with breast- 
milk if obtainable. In one case known to me the breast-milk was pumped 



1 This harelip nipple can be procured from the Miller Rubber Manufacturing Co., 
Akron. Ohio. 



CONGENITAL ADENOIDS. 55 

off every four hours and the infant was nourished by gavage with this milk. 
When breast-milk is not obtainable, then properly modified milk should be 
used, to conform with the age and requirements of the child. If the child 
does not assimilate its food properly, the operation should be postponed until 
tlu i child is built up and strong enough to stand the operation; hence the 
guide for estimating the time for the operation is dependent more on proper 
feeding than on any other factor. 

Hygienic measures are very important, as the irritation by food will 
frequently cause inflammation in the mouth. For details of the surgical 
treatment the reader is referred to the many good text-books on operative 
surgery. 

Tongue-tie (Adh^sia Linguje). 

Tongue-tie consists of an abnormally short fraenum. In some instances 
it may interfere with nursing, and possibly with speaking. It is one of the 
most trivial disorders of infancy. 

Treatment. — Incise the fraenum near its attachment to the tongue with 
a pair of curved scissors. The incision may be enlarged with the aid of 
some dull instrument. Some authors advise using the finger-nail, which 
latter, however, is not aseptic. A tongue-tie should not be operated upon 
if an infection exists in the immediate surroundings. 

The after-treatment consists in using a bland mouth wash, such as a 
1 per cent, listerine solution, or 1 per cent, alum solution, especially after 
feeding the child. 

Congenital Adenoids. 

We occasionally meet with infants in which this condition exists. This 
mechanical impediment prevents breathing through the nose. An infant, 
therefore, is at a great disadvantage, because it cannot breathe while nurs- 
ing. The following case will serve to illustrate this condition ; — 

I was called to see an infant, Mary W., in consultation. The attending physi- 
cian gave me the following history: The infant is twenty days old and weighs 6 
pounds and 14 ounces. At birth she weighed 7 pounds. She was nursed at the 
mother's breast for about one week. The infant seemed to dislike the breast, as she 
would draw and immediately let go of the nipple. The mother believed the infant did 
not like the taste of her milk. A wet-nurse was procured, and the same trouble was 
encountered; the infant would take one swallow and then let go of the nipple in 
order to get her breath. A nipple-shield was then used, but the same difficulty was 
encountered. The family believed that the infant did not like breast-milk, so she 
was given bottle feeding. She took the nipple of the bottle, drew quite well, and 
then let go, when it was necessary for respiration. I ordered spoon feeding, and this 
worked quite well. The breast-milk was pumped from the wet-nurse and fed by 
spoon. This method was successful. The child swallowed a spoonful of milk and 
then had a chance to breathe. An examination of the rhino-pharynx revealed 
adenoids. These were removed with the aid of a sharp spoon, and three days later 
normal conditions existed. 



56 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

The infant was again put to the breast when six weeks old and continued to 
nurse successfully for six months. She was then weaned, owing to the illness of 
the wet-nurse. Cows' milk was substituted. The child is today a perfectly healthy 
little girl. 

Protrusion of the Ears. 

Protrusion of the ears is frequently seen in children. The anxious 
mother will consult the physician regarding the treatment. These cases are 
easily managed in very young infants. A fenestrated cap/ closely fitting to 
the head so that the ears are well held back in their normal position, has 
served me very well. Young infants object to having their heads covered, 
but soon become accustomed to this cap, as it is only worn at night and 
removed in the morning. It is advisable to change the cap frequently, as 
some children perspire from its use. It must be worn for months before any 
benefit is noted. 

In very severe cases in which the above treatment is not successful, it 
may be necessary to call in the surgeon. The operation is a simple one and 
the result is excellent. 

Abnormalities of the Air Passages. 

When there is deficient oxygenation of the lungs, collapse frequently 
occurs, and is called atelectasis pulmonum. This condition is due to the 
unaerated condition of the vesicles. The trouble is usually found in the 
nasopharynx in the form of adenoids, unless some rare malignant condition 
is present. 

Many pigeon-breasted children — with apparent rachitic manifestations 
of the thorax — -owe this anatomical peculiarity more to improper oxygena- 
tion of the lungs than to improper feeding. In such children it is not rare 
to meet with congenital adenoids. (Eead article on "Congenital Ade- 
noids." ) 

It is to be understood that changing the food or giving restorative treat- 
ment, such as iron or codliver-oil, cannot cure such a child until the cause 
is eradicated. 

Congenital Stenosis of the Larynx. 

In the chapter on "Inherited Syphilis" I describe a case of syphilitic 
stenosis of the larynx which necessitated a tracheotomy. Several years ago 
a child was brought to my clinic suffering with cyanosis and difficult breath- 
ing. Intubation was tried without affording any relief. As a last resort 
tracheotomy was performed, but this afforded no relief. A post-mortem 
examination showed that we were dealing with a diverticulum of the trachea. 
In addition thereto the larynx and trachea were lined with a series -of syph- 
ilitic ulcerations. 



1 This cap can be procured at Best & Co.'s, 1 \Yest Twenty-third Street. N. Y. 



CEPHALHEMATOMA. 57 



Peominent Sternum. 

This is frequently called pigeon-breast. It is usually ^v(mi in older 
children. It is occasionally scon as a result of Pott's disease, but more fre- 
quently it is associated with rickets. It has been described by me in the 
chapter on "Rachitis." 

Depressed Sternum. 

Congenital depression of the sternum is occasionally seen in very young 
infants. It is more frequently seen as a funnel-shaped depression, and is a 
symptom of structural weakness. It more often accompanies a general 
rachitic manifestation, to which I call attention in the chapter on "Rachitis." 



HEMATOMA OF THE StERXO-MASTOID. 

During labor traumatic conditions frequently induce haemorrhages. 
These conditions are. therefore, seen in natural labor with very large chil- 
dren, or when forceps are used. Pressure is cited by most authors as one of 
the causes of this condition. Henoch believes that hematoma of the sterno- 
mastoid is caused by twisting the head during labor. The swelling is due 
to an extravasation of blood and to inflammatory conditions of the muscle. 
It is rarely seen before the child is two or three weeks old. There is no 
treatment necessary. The blood is absorbed and the swelling gradually 
disappears. 

Cephalhematoma. 

A swelling is sometimes seen on the top of the head during the first 
few days of the infant's life. It is usually associated with the application 
of forceps or a similar injury during labor. This condition is rare in chil- 
dren, The statistics of the Sloane Maternity Hospital show that this con- 
dition was met with in 20 out of 1300 consecutive births, or 1.6 per cent. 
There may be several swellings. They are most frequently seen over the 
parietal or occipital bone. 

Symptoms. — A swelling that is very soft and fluctuating is noticed. 
This swelling gradually increases in size, and attains its maximum at the 
end of twelve or fourteen days. There is no pulsation palpable. The tem- 
perature is usually normal. 

Diagnosis. — This condition is frequently mistaken for encephalocele. 
The latter, however, is always seen in conjunction with the fontanel or along 
the line of the sutures. 

Pressure causes cerebral symptoms. This condition can be confounded 
with hydrocephalus. In the latter the symmetrical enlargement of the whole 
head is alwavs a characteristic feature. 



58 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

Baby M., seven days old, was born with the aid of forceps, after a very diffi- 
cult and dry labor. When the infant was three days old a swelling was noticed on 
the scalp over the left parietal bone. This swelling gradually increased in size and 
felt soft, doughy, and fluctuating. An incision was made which liberated about four 
ounces of clear, fluid blood. Several days later this case was also seen by Dr. Willy 
Meyer, and as suppuration existed it was necessary to treat the wound on general 
surgical principles. The child recovered. 

Treatment. — The above case illustrates the mistake that can be made. 
A hematoma is a benign condition and disappears without treatment. 
Bandaging and compression are unnecessary, but injury to the part must 
be avoided. 

Caput Succedaneum (Spurious Cephalhematoma: 
Supplementary Head). 

This is a swelling of the scalp due to congestion, resulting in an ex- 
travasation of the blood and lymph into the subcutaneous tissue which is 
external to the pericranium. This swelling does not fluctuate. It is usually 
seen in that portion of the head which first presents itself at the vulva dur- 
ing labor. No treatment is required, as this condition usually becomes 
normal. 

Congenital Cyst of the Kidney. 

The literature records an occasional case of this condition. There are 
no symptoms which would be the means of determining this condition dur- 
ing life. The diagnosis is therefore made post-mortem. 




Fig. 22. — Congenital Cystic Kidney, half natural size. ( Langerhans. ) 

Congenital Sacral Tumor. 

J. B., male infant, eleven months old, was brought to my children's service 
at the German Poliklinik. He was breast-fed and appeared in good health. The 
mother noticed a large swelling over the sacral and lumbar regions. The infant did 



CONGENITAL MALFORMATIONS OF TILE RECTUM. 



59 



not seem to be in pain. The growtli was non-inflammatory and did not interfere 
with the movements of tlie legs. The diagnosis of congenital lipoma was made and 
an operation advised. The ease was sent by me to Dr. Geo. F. fthrady for operation 
at St. Francis Hospital. The tumor was removed. The ease recovered. 




Fig. 23. — Congenital Sacral Tumor. (Original.) 



Congenital Malformations of the Eectum. 

E. E. Kirby 1 states that these occur under the following types : — 

1. Congenital narrowing of the anus or rectum, without complete 
occlusion. The anal aperture is at times preternaturally small, either in 
consequence of a contraction of the lower end of the rectum, or from the 
fact that the skin may extend occasionally over the border of the anal mar- 
gin. The diagnosis is usually easy, for the contraction is near the anus and 
can be readily detected by the finger, or seen when due to a fold of skin 
extending across the anus. The treatment consists in dividing the ring or 
skin on the dorsum, and daily dilatation, either with the finger or soft-rubber 
bougie. 

2. Closure of the anus by a membranous diaphragm (atresia of the 
anus) is the simplest of all forms of congenital malformations, and is treated 
by a crucial incision through the membrane. 

3. In imperforate rectum one may expect to find some of the most diffi- 
cult cases of malformation, although some are comparatively simple. In- 
stead of a normal anus the skin of the perineum extends across the anal 
region from side to side, and the rectum may terminate quite a distance 
from the normal site of the anus. The intervening space may be made up 
of connective tissue, while a circular elevation or depression marks the nor- 
mal site of the anus. Occasionally a distinct fibrous cord may be traced 






'Congenital Rectal Malformations." Archives of Pediatrics, August, 1S97. 



60 ABNORMALITIES AND CONGENITAL MALFORMATIONS. 

from the rectal pouch to the skin. If the rectal pouch be not at too great 
a distance from the skin, a sense of fluctuation may be felt by firm pressure 
of one finger over the anus and the hand over the abdomen. 

4. The system which separates the anal and rectal pouches in cases of 
imperforate rectum with a normal anus is generally within easy reach of the 
anus. It may be perforated and slow dribbling of meconium allowed. There 
may also be more than one septum. 

5. The anus may be absent and the rectum open at any point in the 
perineum or sacral region. The lower portion of the rectum in these cases 
is usually of a fistulous character, lined by true mucous membrane, and the 
abnormal anus is always narrow and insufficient for its purpose. Occasion- 
ally the rectum terminates in two distinct openings, at a greater or less 
distance from each other. 

6. The anus may be absent and the rectum terminate in the bladder, 
urethra, or vagina. In females the vaginal opening is the most common; 
in males the vesical. This condition is usually rapidly fatal unless relieved 
by prompt surgical interference. 

7. The rectum or the large intestine may be entirely absent. 
Kirby lays down the following rules : — 

1. An operation should always be performed, and performed without 
delay. 

2. If there be any chance of establishing an opening at the normal site 
of the anus, the surgeon should at first direct his attention to this procedure. 

3. The use of a trocar as an aid in finding the rectal pouch before or 
after incision through the perineum is not sanctioned by modern surgical 
authority. 

4. The results of attempts to establish an outlet for the imperforate 
rectum through the perineum are not favorable as regards the production 
of a useful anus. 

5. In case of failure to establish a new anus in the anal region, colotomy 
should at once be performed. 

6. In the formation of an artificial anus the left groin is the best site 
for the operation. 

7. Attempts at establishing an anus in the anal region after a colotomy 
are attended with great danger, and are generally unsuccessful. 



PART III. 

FEEDING IN HEALTH AND DISEASE. 



CHAPTEB I. 
BREAST MILK AXD WET-NURSING. 

Colostrum. 

Colostrum is found in the breast of a woman several hours after giving 
birth to her baby. It resembles milk, but is a much thinner fluid. It is 




COLOSTRUM- 
CORPUSCLES 



1 Fig. 24. — From a drop of milk on the third day after delivery, kindly 
furnished by Dr. H. L. Collyer. showing colostrum corpuscles. The specimen 
drawn by Dr. Julian W. Brandeis. (Zeiss Ocular 4, dd Lens.) (Original.) 

always the forerunner of a healthy normal secretion of breast-milk, which 
usually appears on the third day after the birth of the infant. 

Colostrum corpuscles have been described by Czerny as lymphoid cells, 
whose function is to absorb and reconstruct unused milk globules and to 
convey them from the milk-glands into the lymph-channels. These cor- 
puscles usually disappear in one week or ten days after birth. When colos- 
trum corpuscles are present after one month, then such milk will cause 
gastric disturbances. It is a wise plan to examine the milk microscopically 
whenever the slightest evidence of gastric or intestinal disturbance is noted. 

According to Baginsky, colostrum contains large quantities of serum- 
albumin, and is also very rich in fat and colostrum corpuscles, and contains 



From '"'Infant Feeding in Health and Disease. 



Louis Fischer. Third Edition. 
(61) 



62 INFANT FEEDING. 

Table No. 8. 1 
Properties of Human Milk. 

Appearance. Bluish, semitransparent, no odor, sweetish. 

Specific Gravity. 1026 to 1036. 

Reaction. Amphoteric, relation of alkalinity and acidity as 3 to 1. 

n T3 m- f Does not coagulate, and forms a very thin, hardly-per- 

l ceptible skin. 

Coagulates. At ordinary temperature after several hours. 

Coagulates on addi- c . 

, . f T h f • J Coagulates imperfectly m small isolated flakes, which 

, 1 do not precipitate as a uniform coagulum. 

-p , f Yellowish white, resembling cow-butter. Specific gravity 

I at 15° G, 0.966. Melts at 34° C. 

Varieties of Fat. Butyrin, palmitin, stearin, olein, myristin, caproin. 

Behavior of Various f Few volatile acids. More than half of the non-volatile 
Acids. 1 consist of oleic acid. 



rDiffi( 

sin. x cij 
I dis 



Difficult to precipitate with acids and salts. The pre- 
Milk-plasma Casein. cipitate redissolves in excess of acids. During pepsin 

digestion there is no pseudonuclein produced. 



f Lactalbumin and lactoglobin ; relation of casein to albu- 
Composition of Albu- J min, 0.5 to 1.2 or 1 to 2.4; of the 1.3 per cent, 
minoids. albumin, there are 64 parts of casein, and 37 parts 

I of globulin and albumin. 

Solids. Less solids than in cows' milk, especially CaO — P 2 5 . 



Quantitative Analy- 
sis, accoi 
Soxhlet. 



Analy- r 
dine to J Water > 87.41; albuminoids, 2.29; fat, 3.78; milk-sugar, 
g ( 6.21; solids, 0.31. 



Bacteria. Usually sterile, rarely staphylococcus albus and aureus. 



1 From "Infant Feeding in Health and Disease." Louis Fischer, Third Edition. 



PROPERTIES OF COWS' MILK. 



63 



Table No. 8a. 
Properties of Cows' Milk. 



Appearance. 
Specific Gravity, 



( Opaque white or whitish yellow, in thin layers bluish 
C white, slight odor, faintly sweet. 



1028 to 103G. 



Reaction. 



{Amphoteric; relation between alkalinity and acidity, 
2 to 1 ; Soxhlet maintains that cows' milk contains 
three times the acidity of human milk. 



On Boiling. 



Does not coagulate and forms a skin containing casein 
and lime-salts. 



Coagulates. 



Coagulates very soon, owing to lactic-acid formation. 



Coagulates on addi- 
tion of Lab-fer- 
ment. 



f Coagulates to a solid mass at body-temperature, from 
which a yellowish fluid can be expressed. 



Fat. 



Yellowish-white mass. Sp. gr. at 15° C, 0.949 to 0.996. 



Varieties of Fat. 



Palmitin, olein, stearin, myristin, caprilin, caprin, 
caproin, butyrin, laurin, lecithin, cholesterin, and yel- 
low coloring matter. 



Behavior of Various 
Acids. 



Volatile fatty acids, about 70 per cent.; not volatile, 
0.3 to 0.4 per cent, of oleic; the remainder consists of 
palmitic and stearic chiefly. 



Milk-plasma Casein. 



( Easy to precipitate with acids and salts ; excess of acid 
1 does not dissolve ; belongs to the nucleo-albumin group. 



Composition of Albu- 
minoids. 



Less lactalbumin and globin; the largest portion of the 
albuminoids is casein. Relation of casein to albumin, 
0.3 to 3.0, or 1 to 10. 



Solids. 



Cows' milk contains more solids than human milk. 



Quantitative Analy- 
sis, according to 
Soxhlet. 



Water, 87.17; albuminoids, 3.55; fat, 3.69; milk-sugar, 
4.88; solids, 0.71. 



Bacteria. 



Contains all milk bacteria, frequently also pathogenic 
bacteria, as typhoid, diphtheria, and tubercle ba- 
cilli, etc. 



64 IX FAX! FEEDIXG. 

a large quantity of salts. The last two ingredients are supposed to be the 
cause of the laxative action of the colostrum. 

When colostrum corpuscles persist in breast-milk, in spite of the regu- 
lated diet and the hygienic condition of the mother, then breast-feeding 
must be discontinued. A very fretful and nervous mother will frequently 
have colostrum corpuscles in her milk. An instance of this kind was seen 
recently by me. Substitute feeding will frequently modify this condition 
unless there is a specific cause for the same. When a nursing mother is 
very weak and anaemic after her confinement, then iron is indicated. I saw 
a case in consultation recently in which the combined use of fresh air, 
cereals, and iron changed a thin milk containing colostrum corpuscles into 
a thick, creamy milk in less than one month. Continued menstruation or 
uterine disorder with disease in the endometrium may cause profound 
anaemia and thus render breast-milk very thin. Such milk is totally unfit 
for the proper nutrition of the infant. 

An analysis of colostrum milk of a cow by Harrington gave the fol- 
lowing results (Botch) : — 

Fat 1.71 

Milk-sugar 4.90 

Proteids 1.72 

Ash 0.79 

Total solids 9.12 

Water 90.88 

100.00 

The table which follows represents the analysis of the five specimens 
of human colostrum milk, also made by Harrington : — 

Table No. 9. 

I II III IV V 

Fat 1.40 0.68 2.40 5.73 4.40 

Milk-sugar and proteids 9.44 11.53 11.15 10.69 11.27 

Ash 0.17 0.31 0.25 0.16 0.21 

Total solids 11.01 12.52 13.80 16.58 15.8S 

Water 88.99 87.48 86.20 83.42 84.12 

100.00 100.00 100.00 100.00 100.00 

Breast-milk. 

According to Pfeiffer, human milk contains, several days after the 
birth of the baby, a large quantity of albumin, salt, and a small quantity 
of fat. He also found that the longer the period of nursing, the smaller the 
quantity of albumin, which, in the eleventh month, sinks quite low. There 



PLATE IT 




A Drop of Normal Breast-milk from a Primipara. (Original.) 



WOMAN'S MILK. 



65 



is also a decrease in the quantity <>j sails, whereas the amount of sugar 
steadily increases. The fat varies constantly. According to Johannessen, 
the quantity of albumin in the first six months is 1.192 per cent.; in the 
next six months 0.989 per cent., and at the end of the year 0.907 per cent. 

Breast-milk varies according to the Length of time that it remains in 
the breast, and also the length of the nursing period; so it has been shown 
that the first milk taken at the beginning of the nursing aet is the poorest- 
in nutrient value, whereas the last milk is richest in fat. The longer the 
milk remains in the glands of the breast, the more will the solid substances 
of the same be absorbed, so that only a watery solution remains. If sucking 
is commenced, this stimulation soon changes the character of this watery 
milk, so that normal milk will soon be secreted. Forster studied the chem- 
ical constitution of the first, middle, and the last portions of milk from a 
nursing woman, with the following result. 

In one hundred parts he found : — 

Table No. 10. 



First Portion of the 
Nursing Act. 



Second Portion Dur- 
ing Nursing. 



Third Portion at the 
End of the Nursing 
Act. 



Water 

Nitrogenous Substances . 

Fat 

Sugar 

Ash 



90.24 
1.13 
1.70 
5.56 
0.46 



89.68 
0.94 
2.77 
5.70 
0.32 



87.50 
0.71 
4.51 
5.10 
0.28 



The quantity examined was 37.3 grams. 

From a study of the foregoing tables we find a decrease of nitrogenous 
substances during the course of the nursing, a steady increase in the amount 
of fat, and an unvarying percentage of sugar. Thus, it is apparent that, in 
order to submit a specimen of breast-milk to a chemical examination, it is 
necessary to stimulate the secretory functions of the mammary glands by 
putting the child to the breast at least two minutes; thus an even milk can 
be procured. If this rule is overlooked, then we shall find proportions in 
the chemical components of milk which might otherwise be entirely dif- 
ferent. The most recent chemical analysis of breast-milk shows that in a 
hundred parts there are: — 

Solids 11.5 

Liquids SS.5 

Of the solid constituents there are: — 

Casein 1.2 to 1.03 

Albumin 0.5 

Fat 0.S to 4.07 

Milk-sugar 0.0 to 7.03 

Ash 0.2 to 0.21 

s 



66 INFAXT FEEDING. 

The above is the chemical examination of a good average breast-milk. 
1 again eall attention to the fact, however, that not only does the milk vary 

in different women, but it also varies in the same woman during one single 
nursing act. 

The albuminoids of milk consist of real casein, lactalbumin, globulin, 
and opalisin. This latter body has only recently been discovered by A. 
. vVroblewski. and more recently by Schlossmann. 

Phosphorus exists in milk as nuclein-phosphorus. Wittmaack has 
demonstrated the fact that the phosphorus in woman's milk exists as an 
organic nitrogen compound in the casein. 

According to the examination of Stolasa, lecithin contains a larger 
quantity of phosphorus in woman's milk than in cows' milk. 

The specific gravity of breast-milk varies from 1026 to 1036. 

The Mammary Glands. — The mammary glands of the same woman 
may yield somewhat different milk, as shown by Sourdat and later by 
Brunner. Also the different portions of milk from the same milking may 
have different compositions. The first portions are always poorer in fat 
(Parmentier, Peligot, and others). 

According to l'Heritier Yernois and Becquerel, the milk of blondes 
contains less casein than that of brunettes : a difference which Tolmatscheff 
could not substantiate. Women of weak constitutions yield a milk richer in 
solids, especially in casein, than women with strong constitutions. 

According to Yernois and Becquerel. the age of the woman has an effect 
on the composition of the milk, so that we find a greater quantity of proteids 
and fat in women 15 to 20 years old and a smaller quantity of sugar. The 
smallest quantity of proteids and the greatest quantity of sugar are found 
at 20 or from 25 to 30 years of age. The milk with the first-born is richer 
in water — with a proportionate diminution of the quantity of casein, sugar, 
and fat — than after several deliveries. The influence of menstruation seems 
to slightly diminish the milk sugar and to considerably increase the fat and 
casein. 




Fig. 25. — Heeren's Pioscop, for Optical Milk Test. 

Pioscop. — One drop of milk can be examined in the pioscop and com- 
pared with the colors on the same. This is a rapid but rough method of 
estimating the richness of the milk. 



WOMAN'S MILK 



67 



Specimen of Breast-milk for Chemical Examination. — After the 
third, possibly Hie fourth, day the average healthy woman secretes milk 
that gradually becomes normal in quality and quantity, depending on 
her genera] condition. It is usual for an infant to lose some weight 
during its first week of life, owing to various physiological changes, added 
to which is. no doubt, the deficiency in the quality and quantity of its 
food. It is a safe plan, and one that I have always urged, if at all pos- 
sible, to send a specimen of breast-milk to a chemist and submit the same to 
a chemical analysis. In some women a specimen can be examined when the 
baby is one week old: in others it is better to wait until the end of two 
weeks. "We then would have a proper working basis, and know just how 
much fat. carbohydrate (sugar), and albuminoids — including proteids — we 
are feeding. Xoting the weight of the child, its sleep, its digestion, color 
and frequency of its stools, we can easily see in one week how much the infant 
has gained in weight, and its general condition. To take a specimen, it is 
advisable to have all utensils absolutely clean; hence the following plan 
would be suggested : Boil an ordinary one or two-ounce bottle in water, to 
which a pinch of baking soda has been added, for about one-half hour. Then 
place the bottle in plain water and boil again for a half-hour. Then turn 
the bottle upside down, and allow it to drain and dry. In this manner we 
can completely sterilize the inside of the bottle and avoid contamination. 

Withdraw a sample of breast-milk by means of a breast-pump. One 
which has served the author very well is known as the Florence breast-pump, 
and has a glass mouth-piece. (See Fig. 35.) Another form is an English 
breast-pump, having a rubber bulb. Compressing this bulb, we can suck 
about an ounce or more in from five to ten minutes. This milk is to be 
poured into the bottle, and well corked, and set in a refrigerator, but 

Table No. II. — Comparative Analyses of Breast-mill;. 



Human ililk. 



Normal Milks, 

Average 

Average 

Average 

Average 

14 analyses from same woman 
Mean of 6, aged 23-33 years . 

Average 

From woman aged 18 

From woman aged 33 

4 days after delivery 

9 days after delivery 

12 days after delivery 

Average of 84 samples .... 
Average of 107 samples .... 



Fat. 


Proteids. 


Sugar. 


Ash. 


2.90 


3.07 


5.87 


0.16 


3.63 


1.70 


7.11 


0.20 


2.67 


3.92 


4.37 


0.14 


3.52 


2.01 


5.91 


. . . 


2.53 


3.42 


4.82 


0.23 


3 82 


2.04 


5.93 


0.42 


3.55 


1.52 


6.50 


0.45 


3.20 


2.39 


6.83 


0.29 


2.99 


2.51 


6.51 


0.30 


4 30 


353 


4.11 


0.21 


3.53 


3.69 


4.30 


0.17 


3.34 


2.91 


3.15 


0.19 


4.13 


2.00 


6.94 


0.20 


3.78 


2.09 


6.21 


0.31 



Authority. 



A. W. Blythe. 

Marchand. 

Vernois & Beoquerel. 

Hammarsten. 

Simon. 

H. Gerber. 

Chevalier & Henrv. 

J. Bell. 

J. Bell. 

Clemm. 

Clemm 

Clemm. 

Leeds. 

Konig. 



68 



INFANT FEEDING. 



not on the ice. Milk will keep for many hours in this way. My plan has 
been to inform the chemist the day previous to submitting the sample, so 
that it can be withdrawn from the breast early in the morning — at about 
8 a.m. — and sent to the laboratory at once. The result of the analysis can 
be received on the evening of the same day or on the following day in all 
instances. A point worth noting is that the very first milk — known as the 
foremilk — should not be used, but the infant should be allowed to suck at 
the breast for about two minutes before pumping the sample. After this 
the breast-pump should be applied for five minutes to procure the so-called 
middle milk for examination; then the infant can again be put to the 
breast to finish the so-called end of nursing or to suck the strippings. 




Fi f ; £6. — Specimen of Breast- 
milk from a Young Mother, 17 years 
old. Primipara, Baby four months 
old; thriving; gaining in weight; 
stools yellow; sleeps well. Chemical 
examination: Fat, 2.60; sugar, 6.50; 
proteids, 2.54. Milk looks creamy, 
and the mammae are well filled. 

(Original.) 




Fig. 27. — Specimen of Breast- 
milk, Illustrating Very High Fat, 
Causing Gastric Disturbance. Baby 
gaining; vomits frequently; stools 
yellowish; bluish white milk; child 
sleeps well; excessive fats. Chem- 
ical analysis: Fat, 5.0; sugar, 6.50; 
proteids, 1.74; ash, 0.20. (Original.) 



Examination of Breast-milk. — A method which can be employed in 
general practice is recommended by Friedmann (Deut. med. Woch., Jan. 
23, 1902). It is more easily done than a chemical analysis, and serves 
an equal purpose. It consists of determining by microscopical examination 
the number and character of the milk corpuscles. It is an advantage first 
to become familiar with the normal conditions by repeated examinations 
of the milk from healthy mothers, those whose children are well and show 
no signs of rickets or glandular enlargements. The milk corpuscles can 
be divided as to size into three groups, large, small, and intermediate, of 
which the latter are most numerous. The small ones are also found in 



WOMAN'S MILK. 69 

almost equal numbers, but the large ones are comparatively scarce, a mag- 
nification of 400 diameters showing only aboui LO-20 in the field. If these 
be more numerous the milk is found to be too fatty and more difficult to 
digest. A preponderance of the small corpuscles usually means a chronic 
dyspepsia for the nursing infant. An accurate count can be made with 
some form of bloo'd-counting apparatus, but the latter is not essential. The 
proximity of the corpuscles to each other also serves as a guide to the grade 
of the milk, the more sparsely distributed the globules and the greater the 
number of the small ones, the poorer the quality of the milk. The method 
also serves to differentiate the character of the milk from the two breasts. 
In the selection of wet-nurses it is obviously useful. 

Reaction of Human Milk. — Bordet has called attention to the precipi- 
tation of the albuminoids in milk when it is added to the serum in animals 
which have been previously injected with milk from the same source. 
Schlossmann found, further, that the fluid from a hydrocele on a breast 
child was also able to precipitate the albuminoids in human, but not in cows' 
milk. Moro now announces that if a few drops of human milk are added 
to a few cubic centimeters of fluid from a hydrocele, in a few minutes the 
hydrocele fluid coagulates into a solid mass. This reaction does not occur 
with cows' or goats' milk. The hydrocele fluid evidently contains fibrinogen, 
and the milk, fibrin ferment. The combination of the two induces the 
coagulation. It occurs even with minute quantities of the milk; all the 
serum in contact with the milk coagulates around it. The same reaction 
occurs when human serum is added instead of the milk, but much less pro- 
nounced and much slower, and the same difference is observed when the 
human milk is boiled or long heated. Particles of coagulated ox blood also 
induced a slow and partial coagulation. 

Diastatic Enzyme in Human Milk and in the Stools of Nurslings. — 
Dr. Ernest Moro reports from Escherich's clinic, in Graz. that : — 

First. — Human milk contains, normally, an intensive, saccharifying 
enzyme, which is not found in cows' milk. 

Second. — This enzyme is found in the stool of breast-fed children and 
signifies a more pronounced diastatic action of the same. 

Th ird. — This diastatic enzyme is secreted by the glands of the intestine. 
Parts of the same can be found in the pancreatic juice of the new-born. 

Fourth. — The intestinal contents and fteces of nurslings contain at 
birth, as a rule, a diastatic enzvme, which increases in the first few weeks of 
life. 

Immunity Conferred by Breast-milk. — The nursing infant is usually 
exempt from infectious diseases, although we do find an occasional case of 
infection in a breast-fed infant. Such is the exception rather than the rule. 

Bead chapter on "Measles" for cases of immunity seen by me in the 
Riverside Hospital. 



"0 



INFANT FEEDING. 



There seems to be an immunity conveyed to the infant through its 
mother's milk. These substances which convey immunity have been 
studied by Brieger and Ehrlich. During epidemics nursing infants rarely 
succumb to infections. The following case will illustrate the manner in 
which immunity can be "conveyed" through the milk: — 

A woman suffering with diphtheria was four months pregnant at the time of 
infection. .She was injected with 2000 units of antitoxin and recovered in about 
six days. Several months after the birth of her child, an older child in the family 
was attacked with diphtheria, which required several injections of antitoxin, also 
intubation, to relieve a severe form of croup. Although the new-born infant was 
in the same room it did not show any signs of the disease. This was most likely due 
to the immunity conferred upon the child by its mother through her breast-milk. 

To Preserve Human Milk. — Human milk collected from various 
women may be preserved for many weeks if treated in the following 
manner: Test the milk with litmus paper to be sure that it is ampho- 
teric or alkaline. If it is not alkaline, add a few drops of bi-carbonate 
of soda solution. Then add 0.2 cubic centimeters of a concentrated 30 
per cent, perhydrol solution. This quantity of perhydrol is sufficient 
for 400 cubic centimeters milk. The milk is then thoroughly shaken so 
that the perhydrol produces its chemical effect. On close inspection 
small bubbles can be seen in the milk. Lastly the milk is heated for ten 
minutes in a water bath to 120 degrees F. Milk so treated by Dr. 
Meierhoffer was tasted by me in the Children's Wards of Dr. Paul Moser, 
in Vienna, and seemed perfectly fresh although it was one month old. 

Table No. 12. — Five Analyses of Human Breast-milk. 1 





Case 

No. 1. 

Per cent. 


Case 

No. 2. 

Per cent. 


Case 

No 3. 

Per cent. 


Case 

No. 4. 

Per cent. 


Case 

No. 5. 

Per cent. 


Water 


86.2 
1.7 
6.5 
5.4 
0.2 


89.0 
1.3 
5.8 
2.5 
0.3 


87.0 
1.6 
6.6 
3.8 
0.2 


88.6 
1.1 
6.7 
2.7 


88.1 


Proteids 


1.1 


Lactose 

Fat 


6.2 
4.1 


Salts 





Case I of Table 12 showed symptoms of gastric disturbance, chiefly 
vomiting, caused by "feeding high fat." The mother of the infant believed 
that by eating frequently and of very rich food, she would benefit her baby, 
thus her milk showed 5.4 per cent, of fat. 

By reducing her diet, excluding meat and too many eggs, discontinuing 
alcoholic and malted beverages, her milk improved, the fat being decreased. 
Exercise, such as walking, was ordered for the mother. 



1 Analyses made by Lafayette B. Mendel, Yale University, New Haven, Connec- 



ticut. 



BREAST-FEEDING. 



71 



Table No. 13. — Tabic Showing Analyses of a Norma?, a Poor, 
an Over-rich, and a Bad Human Breast-milk. 1 



Fat 

Sugar 

Proteids 

Mineral Matter . 

Total Solids . . . 
Water 

Total .... 



Normal Milk. 
Exercise and 
Good Food. 



4.00 

6.50 

1.75 

.19 

12.44 

87.56 

100.00 



Poor Milk. 

Poor Food. 

(Low Fat. 

High Proteids.) 



1.00 

6.50 

2.36 

.24 

10.10 

89.90 

100.00 



Over-rich Milk. 

Rich Food, 

No Exercise. 

(Excess of Fat. ) 



6.59 

6.69 

1.16 

.19 

14.63 

85.37 

100.00 



Bad Milk. 

Wet-nurse 
Menstruating. 

(Low Fat. 
Low Proteids.) 



.65 
6.50 
1.12 

.11 

8.38 
91.62 

100.00 



Specimens examined by Mr. Bailey, chemist of the Pediatrics Laboratory. 



Breast-feeding. 

During the first month feed every two hours, but never oftener. Dur- 
ing the second month ever}' two and a half to three hours. 

During the day disturb the child every two hours, to be nursed; but 
during the night leave the child rest as long as it appears satisfied. This 
rule applies to healthy children only. In sickness special rules for feeding 
are required. If the child thrives and gains in weight, then it is advisable 
and in the interest of the mother and child to have an interval of from seven 
to eight hours at night; thus Bouchut advises feeding between 10 and 11 
at night, and commencing the morning meal at 6 a.m. If the child is rest- 
less, then turn it from side to side ; in other words, changing its position and 
giving it one or two teaspoonfuls of boiled water will frequently satisfy it 
and prolong its sleep. 

Table No. 14.— Time for Feeding. 



From Birth 


Until 1 Month 


Old. 


6 A. 


M. 


8 A. 


M. 


10 A 


M. 


12 Noon 


2 P. 


M. 


4 P. 


M. 


6 P. 


M. 


8 P. 


M. 


10 P. 


M. 


12 Mid- 


night 


2 A. 


M. 



From 1 to 2 
Months Old. 



6 A. M. 

8 A. M. 
10 A. M. 
12 Noon 

2 P. M. 
4 P. M. 
6 P. M. 
8 P. M. 

12 Mid- 
night 

3 A. M. 



From 2 to 4 
Months Old. 



6 A. M. 
8.30 A. M. 

11 A. M. 
1.30 P. M. 
4 P. M. 
6.30 P. M. 
9 P. M. 

12 Mid- 
night 



From 4 to 6 
Months Old. 



6 A. M. 

9 A. M. 
12 Noon 

3 P. M. 

6 P. M. 

9 P. M. 
12 Mid- 
night 



From 6 to 9 
Months Old. 



A. M. 
30 A. M. 

P. M. 
30 P. M. 

P. M. 

Mid- 
night 



From 9 

Months Until 

1 Year Old. 



6 A. M. 

10 A. M. 

2 P. M. 

6 P. M. 

10 P. M. 



*I am indebted to the chemist of the Walker-Gordon Laboratory for a series of 
chemical analyses herein reported. 



72 INFANT FEEDING. 

The first three or four days require special feeding methods. On the 
day of the birth, the exhaustion of the mother and presence of colostrum, 
besides the normal deficient quantity of food in the breast, demand large 
intervals of rest. Thus "for the first three days (unless the milk-supply is 
profuse) putting the infant to the breast once in six hours is sufficient; if, 
however, the supply of milk is ample, then we can follow the table given 
above and nurse the infant every two hours. 

Suggestions for Breast-feeding. 

The mother or wet-nurse should always sit upright, be it at night or 
during the day, while nursing the infant. 

Danger of Suffocation. — A great many cases are on record where the 
mother or wet-nurse has fallen asleep while nursing and smothered the in- 
fant. For this reason if is important that the infant should sleep in its 
own crib or bed, and should never sleep with the mother or nurse. 

Shall an Infant Receive but One or Both Breasts for One Meal? — 
This depends on the infant's appetite. Some infants appear satisfied 
after nursing from one breast, and will let go of the nipple and fall asleep. 
Lightly tapping the cheeks of the infant will awaken it, or the withdrawal 
of the nipple from the infant's mouth will frequently arouse it to continue 
nursing. If, however, the infant will not renew its nursing, and still con- 
tinues to sleep, and if the infant has nursed steadily for ten minutes, then 
the sleep should not be disturbed. 

Length of Time for Nursing. — A good plan is to note the time when 
the nursing act commences and stops. Xo infant should nurse longer than 
twenty minutes, whereas frequently ten or fifteen minutes will suffice. If 
an infant nurses more than twenty minutes, say thirty or forty minutes, 
then we may be sure that the breast-milk is deficient in quantity and a 
specimen should at once be submitted for a proper chemical examination. 

Scanty Breast-milk Eequiring Mixed Feeding. 

When there is a deficiency in the quantity of breast-milk, but the quality 
is good, then it is advisable to feed the infant alternately with breast-milk 
and bottle-milk. At the same time it is advisable to direct attention to the 
mother's general condition, and see if we cannot tone her up, and thus im- 
prove both quality and quantity of her milk. Frequently a subnormal or an 
anaemic condition requires iron. A day's outing to the country or seashore, 
with moderate exercise, will stimulate and increase the flow of milk. Every 
drop of breast-milk is so precious that no infant should be deprived of it, 
and wise is the physician who will insist upon giving all breast-milk. When 
there is deficient lactation, supply the deficiency by giving a properly diluted 
milk or cream mixture, adapted for the age and weight of the infant. 






nisri i;i;\m i> Dl RING BREAST FEEDING. , :; 

To Increase the Quantity of Breast-milk. — Some of the galaciagogues 
have given me satisfaction, in addition fco a nutritious diet, such as meat, 
milk, and eggs. A preparation on the market known as Nutrolactis^ lias 
proven a most valuable galactagogue. It is given in tablespoonful doses 
three times a day. This will not only stimulate the quantity, but also the 
quality, of the milk. Grandin and Jarman, in their text-hook on "Obstet- 
rics/' recommend the strong infusion of galega officinalis when the flow of 
milk is scant. This is to be ordered in tablespoonful doses three or four 
time- a day. 

Xomaiu.se in Cases of Deficient Lactation. — "A primipara who secreted only a 
limited amount of colostrum, and kept that up so that the child was crying from 
hunger and had to he artificially fed, was put upon somatose, 4 teaspoonfuls a day, 
and in three days the patient secreted a sufficient quantity and quality of milk to 
satisfy the child, which increased one-fourth of a pound regularly each week. It 
seemed difficult to induce the mammary glands to perform their proper function; 
hut when somatose was given there was a normal supply of milk, and the child was 
properly nourished without artificial feeding.'' 

Do Drugs Taken by a Nursing Woman Affect the Baby? 

Physiological experiments have frequently demonstrated, the fact that 
a great many drugs can be given to an infant through the milk ; thus, opium 
and morphine and narcotics in general do affect the infant, when taken by 
the mother. Baginsky calls attention to this fact in his text-book on "Dis- 
eases of Children" : "Alcohol, when taken by the mother, is transmitted 
through the milk, but not in very large quantities. The following is a list 
of drugs which have been found in milk : The purgative principles of rhu- 
barb, senna, and castor-oil; the metals, antimony, arsenic, iodine, bismuth, 
lead, iron, mercury; the volatile oils, like copaiba, garlic, and turpentine; 
also salicylic acid, and the iodides and bromides/' Do not give cocaine, 
chloral, atropine, or hyoscyamus. Care is to be used with the following: 
Digitalis, antipyrin, and ergot. An unpleasant flavor can be imparted to 
the breast-milk by the mother or wet-nurse eating onions, turnips, cauli- 
flower, or cabbage. 

Disturbances During Breast-feeding. 

Quite frequently we meet with gastro-intestinal disorders in infants 
that are wholly breast-fed. These disturbances are due to (a) insufficient 
exercise; (b) faulty diet; (c) extreme nervous irritability; (//) menstrua- 
tion while nursing; (?) physiological changes in the woman causing an 
improper ratio of ingredients. Some of the causes just mentioned can easily 
he remedied. On the other hand, a very nervous woman, whose anxiety keeps 
her constantly fretting during the day and awake at night, will hardly be 



1 Sold in all drug stores. 



74 INFANT TEEDING. 

adapted for breast-feeding, and the sooner the infant is removed from such 
a breast, the better for the infant. 

The following cases will illustrate the above conditions: — 

An infant was nursed by its mother. The mother was extremely nervous, 
fretful, did not sleep at night, and nursed her child too often. 

The infant suffered with colic, had greenish, cheesy stools, and did not gain in 
weight. Had indigestion and all evidences of intestinal colic. The case was seen 
by me through the courtesy of Dr. A. A. Richardson, of New York City. The physi- 
cian assured me that the mother would not leave her home, and that she had had 
no outdoor exercise, no fresh air, and nothing but the constant worry of a sick, crying 
baby which she nursed as best she could. A chemical examination of the breast- 
milk showed the following: — 

Fat 1.20 

Sugar 6.50 

Proteids 1.70 

Ash 0.18 

Total solids 9.58 

Under the influence of exercise and careful diet the fat was increased. In this 
case we alternated breast and bottle feeding, and gave the child mixed feeding. A 
formula of 2 per cent, fat, 5 per cent, sugar, and 0.75 per cent, proteids was pre- 
scribed at the Walker-Gordon Laboratory. 

An infant one month old was seen by me in the family of Dr. J. Grosner, of 
this city. The infant had been vomiting, had had colic, and was very restless. The 
mother was very nervous, but had an abundance of milk. From the history I 
learned that the child had an explosive vomit, the food coining out, besides large 
quantities of gas. There were five to seven stools in twenty-four hours. The bowels 
moved at each nursing. The chemical examination of the breast-milk showed: — 

Fat 4.00 

Sugar 6.50 

Proteids 3.05 

Ash 0.30 

Total solids 13.85 

From this examination it can be seen that for a baby six months old 
there was an excess of fat and also a very high percentage of proteids. 

An infant one to two months old requires 2 per cent, of fat. Xote also 
a normal infant receives between 1 and iy 2 per cent, of proteids, while this 
child received more than 3 per cent, of proteids. There being a profuse 
secretion of milk, the child received far more than it could digest in both 
quality and quantity. .The feeding interval was lengthened, and the time 
of nursing was reduced to five minutes, whereas until the appearance of 
vomiting the child nursed twenty minutes. An ounce of sterilized water was 
ordered immediately after each nursing, hoping to thus dilute the milk. 
This method proved successful. 



BREAST MILK. 



<•> 



.1 Case of Prolonged Lactation, Showing Deficiency of Nutriment. — A child, 

about 1 year old, was brought to me with the following history: It had no teeth. 
Can neither stand nor walk. It is colicky. Does not Bleep well. Docs not gain 




Fig. 28. — Showing a Drop of Milk under the Microscope. Note the 
poor character of this emulsion, the uneven fat-globules, and their irregular 
size and distribution. The infant nursed with the above milk was rachitic 
and colicky. Although 15 months old, no tooth had appeared. The mother 
of the infant states that she menstruated every twenty-one or twenty-two 
days since her infant was born — during this present nursing period. 
( Original. ) 




Fig. 29. — This Drop of Breast-milk is from a very Anemic Woman. 
The child was extremely emaciated, had greenish stools and colic, and was 
always crying. Xote the uneven character of above emulsion, when com- 
pared with Plate IV. The infant was poorly nourished; had rickets and 
marked cranio-tabes. Mixed feeding was resorted to, with decided improve- 
ment. (Original.) 

weight. The child was nursed every three or four hours. The mother was very 
nervous, and menstruated almost every month during lactation. The chemical anal- 
ysis of the milk gave: — 

Fat 1.22 

Sugar 7.07 

Proteida 0.9S 



76 .. INFANT FEEDING. 

It was very evident that this baby was receiving poor milk, very low fat, and 
deficient proteids. The infant was weaned, artificial feeding was prescribed, and the 
infant immediately showed a gain in weight. The symptoms of colic disappeared. 

Illustration of Prolonged Lactation Without Apparent Harmful Effects. — An 
infant fifteen months old was brought to me for the relief of constipation. It had 
ten teeth, was able to stand and walk, and was beginning to talk. Ihe infant was 
still breast-fed. The analysis of the milk gave the following: — 

Fat 2.86 

Sugar 6.78 

Proteids 1.76 




Fig. 30.— Holt's Milk Test Set, for Testing Human Milk. 

The infant's weight in this ease was normal, and I must regard this 
prolonged lactation, showing such good result, as an exception rather than 
a rule. 



Additional Foods Durixg the Nursing Period. 

When a nursing infant is six to nine months old, certain additional 
foods can be given; thus, for example, the white of a raw egg can be given 
every second day, and on the alternate day several ounces of a meat soup 
(beef or chicken) in which barley, farina, or sago has been boiled and 
strained. This method of feeding can be kept up until the child is about 
1 year old. A small piece of zwieback or rusk can be allowed every day. 
As this is hard, children like to nibble on it. It seems to soothe their gums. 



FLOUR-BALL FEEDING. 77 

Flour-hall Feeding. — This is highly recommended by Dr. Edwin Rosen- 
thal. 1 lie 1 says: "J use the following formula, and I can claim as good 
results therefrom as from any form of home modification. It is known as 
the flour-ball food, commercially imperial granum. Jt is made as fol- 
lows : — 

'"Plain wheat-Hour is boiled in a bag for five hours; it is then baked 
in an oven until perfectly hard and dry. After cooling it is broken open, 
the rind rejected, and grated into a powder. For a child one month old 
1 order: — 

Scalded milk % pint 

Sterile water 1 pint 

Grated flour-ball 1 heaping tablespoonful 

"The milk is placed on the fire and heated: the flour is rubbed into a 
paste with the water and added to the milk. This is brought to the boiling 
point, taken from the fire, set aside to cool, and then placed on the ice. 
Finally add enough raw milk to make two pints in all. At feeding time the 
required amount is heated to feeding temperature. 

"For a child one month old, two ounces are given every two hours. It is 
increased a half-ounce every month." 

I advise ueing the following formula for a child six months old : — 

Flour-ball 1 teaspoonful 

Rice water 4 ounces 

Raw milk (certified or guaranteed) 4 ounces 

Granulated sugar 1 teaspoonful 

Rub up the flour-ball with a little rice water, and gradually add the 
full quantity. Add the sugar, and lastly the raw milk. Heat to a tem- 
perature of 150° F. for two or three minutes. 

One bottle containii^g the above can be given instead of a breast-feeding, 
or if the milk is scanty we can alternate a breast-feeding with a bottle- 
feeding- of the above formula. If this feeding agrees, but the child appears 
hungry after the bottle, the milk may be increased and the rice water de- 
creased gradually, one ounce at a time, until full milk is given. The guide 
for increasing the food should be a yellowish pasty condition of the stool, 
the increase in weight, and the absence of colic. 

The Diet of a Nursing Mother. 

Immediately after the birth of the child the exhausted condition of a 
woman following labor will certainly call for rest; hence sleep is imperative, 
after which some form of stimulation is required. This can best be accom- 



1 Taper read before the Pennsylvania State Society, May 18, 1898, entitled 
'Some Points on Infant Feeding." 



78 INFANT FEEDING. 

plished by giving at intervals of several hours good, wholesome food, as 
chicken broth or beef broth, weak tea, or strained gruel. It is unnecessary 
to state that each woman's case and her former habits must be taken into 
consideration in prescribing a diet. If labor has been normal, then the nour- 
ishment will stimulate the milk. If warm liquids are not well borne, then 
cold drinks like buttermilk, koumyss, zoolak, or iced tea should be em- 
ployed. Iced champagne will frequently do more good to allay gastric irrita- 
bility than all medication. Raw milk in combination with seltzer or lime- 
water is indicated. In some instances ice-cream will aid nutrition and alle- 
viate gastric irritation. If the pelvic condition is normal, then it is wise 
not to give solid food for the first three days, but, rather, stimulate the milk- 
glands by giving meat broths, farinaceous gruels, and by all means milk. 
Zwieback soaked in milk or in tea is highly nutritious and easily digested. 
Other nutritious foods are calfsfoot jelly and chicken jelly. 

After the third day, if the pelvic organs are normal, it is wise to con- 
sider the action of the bowels. If the bowels have not moved by this time, 
then buttermilk added to the diet or stewed prunes or peaches, baked apples, 
or grapes will aid in establishing a movement of the bowels. 

If the milk is scanty and the bowels have not moved, then the best 
remedy is a large tablespoonful of palatable castor-oil, modified to suit 
the taste by the addition either of lemon juice or orange juice, or by adding 
several drops of the ordinary spirits of peppermint. After the bowels have 
been evacuated and the general condition warrants it, then a diet consisting 
of the following is indicated : — 

BREAKFAST, 7 TO 8 A.M. 

Hominy and Milk. Grapes. 

Farina and Milk. Soft-boiled Eggs. 

Eice and Milk. Poached Eggs. 

Oatmeal and Milk. . Eggs on Toast. 

Germea and Milk. Coffee and Milk. 

Cream of Wheat and Milk. Tea and Milk. 

Some Stewed Prunes, Figs, or Cocoa and Milk. 

Peaches. Toast and Butter. 

Stewed Apples. Stale Bread (2 days old), with 

Oranges. Butter. 

I do not advise meat or fish in the morning, unless the nursing mother 
has always been accustomed to this form of diet. 

LFXCTT, 12 TO 1 P.M. 

Some soup made from meat, either veal, beef, mutton, lamb, or chicken, 
containing also some rice, barley, farina, sago, or hominy; it should not 
be highly seasoned, and should not be strained. 



DTET OF A NURSING MOTHER. 



79 



Fish, boiled or fried, and all shell-fish, particularly oysters, are very 
nutritious during the nursing period. 

Ji' the appetite warrants it. thru a piece of steak or chop, roast heel'. 
chicken (white meat only), or raw chopped meat, with bread and butter, 
is very nutritious. 



EVENING, 6 TO 7 P.M. 



A Bowl of Oatmeal Gruel. 
Stewed Oysters. 
A Drink of Milk. 

Farina Pudding-. 
Bice Pudding. 

Cornstarch Pudding. 



Junket. 

Cup of Tea. 

Eggs, if desired. 

Meat, if in the habit of eating 



it in the evening. 



For Thirst. — Cool, filtered water, or the alkaline waters, like Seltzer 
and Apollinaris. 

// the milk is scanty, the flow can be stimulated by drinking a cup of 
hot broth, made from beef, chicken or veal, lamb or mutton, several minute* 
before putting the child to the breast. 

Alcoholic Drinks. — If the woman is in the habit of drinking wine or 
beer, then it is unwise to discontinue the use of alcoholics in moderate 
quantities while she is nursing. I have seen a great many women whose 
flow of milk was scant who immediately secreted an abundance of milk 
after partaking of a glass of beer, or ale, or porter with their meals for sev- 
eral days. Beer has a decided laxative effect, and this in itself is rather an 
advantage for those nursing mothers having a tendency to constipation. So 
my rule, therefore, would be to insist on abstinence from wine and beer 
unless the patient has been in the habit of taking it formerly. 



FOODS TO BE AVOIDED BY A NURSING VTOVfAN. 



Onions. 
Garlic. 
Cabbage. 

Powerful Salts (Rochelle, Glau- 
ber, Epsom). 



Ethereal Oils. 

Butter and Fat moderately. 
Candies and too much Sweets. 
Large quantities of Potatoes. 



Inability of Mothers to Nurse tttetr Ctttldeen. 

It is surprising to note the gradual disappearance of the healthy, robust 
American mother who can perform the duty of nursing her infant. The 
following table will give a fair illustration of the conditions as they exist in 
New York City to-day : — 



80 INFANT FEEDING. 

Table No. 15. — A study of 1000 Mothers and their ability to nurse. 



Mothers. 


Condition 

of 
Mother. 


Able to Nurse 

9 Months to 

1 Year. 


Able to Nurse 
4 Days to 
2 Months. 


Primiparas. 


Multiparas. 


500 1 


Living in Tene- 
ment Houses. 












Very Poor. 


450 2 


50 


210 


290 


500 


Livirg in 

Healthy 

Portions of 












the City. 
Prosperous. 


84 


150 


305 


195 



According to the above statistics, 90 per cent, of the poor mothers are 
able to nurse their children, while only IT per cent, of the rich mothers 
are able to perform the same duty. 



Wet-nurse. 

Two important points are necessary: First, the presence of suitable 
milk; second, the absence of a constitutional taint or acute severe illness. 

What to Examine. — First, the breasts for the quantity of milk present. 
The breast should be gently but firmly held at some distance from the 
nipple; thus we can learn by palpation regarding the parenchyma of the 
glands. Also the quantity of milk which, if expressed continuously about 
twenty to thirty seconds, should flow in several streams. 

Stagnant milk always shows sensitiveness on pressure. The statement 
of a wet-nurse that her "milk is deficient in quantity" can be determined by 
subjecting her to careful observation for several hours. After this time the 
milk in the breasts should be expressed and the quantity determined. 

The ease with which milk can be expressed by palpation is an impor- 
tant factor to note. If the milk flows with great difficulty, and requires 
considerable massage or pumping, then such a nurse is totally unfit to nurse 
atrophic, marasmic, or prematurely born babies. 

Weak or marasmic children require a wet-nurse having a plentiful 
supply of milk. Thus the slightest palpation while expressing must yield 
a liberal flow of milk. 



1 Thirty-five, or 7 per cent., of these mothers suffered from puerperal disease, 
such as septicaemia, mastitis, and kindred affections; hence, they were ordered by 
their physicians not to nurse. 

2 Three hundred and twenty-four infants were put on artificial feeding. This 
feeding consisted of feeding at the laboratory and home modifications. One hundred 
and fifty-four of these infants were supplied with wet-nurses, owing to loss of 
weight, dyspeptic conditions, or marasmus during the bottle-feeding. 



WET-NURSE. 81 

Note if the expressing of milk causes pain; in the normal breast it 
should be painless. 

It is not always the quality of the milk, but frequently the quantity, 
that is the cause of poor assimilation of a wet-nurse's milk. In such in- 
stances a chemical examination of the milk is imperative; by this we can 
learn exactly how much we feed an infant in percentages. If necessary, 
we can modify the milk (by proper wet-nurse diet) until the required per- 
centages are attained. 

The Child of a Wet-nurse. — Certain allowances must always be made 
for babies presented by wet-nurses — for instance, if the hygienic surround- 
ings of a wet-nurse are very poor, and in addition thereto her food supply 
is meager, then a general anaemic appearance must be expected. On the 
other hand, a healthy, robust-looking baby must not be regarded as the 
criterion by which we should judge the wet-nurse. 

The tricks of wet-nurses are manifold. Frequently they will procure 
a healthy-looking infant and pass it off as their own, in order that they may 
procure a position. 

Another point is that they will frequently resort to stuffing their babies 
by feeding a bottle in addition to their breast-milk. Thus we must judge 
for ourselves the quality of the wet-nurse physically, and, most important 
of all, by the quality and quantity of her breast-milk. 

Health of the Wet-nurse. — It must be borne in mind that the secretion 
of milk does not so much depend on her constitution as it does depend on 
her nervous system. Great importance must therefore be placed on the 
uselessness of hysterical or neurasthenic women for wet-nursing. 

The phlegmatic temperament — the broad shouldered, easy-going woman 
— pleasant and gentle mannered, is the one most useful and best adapted for 
wet-nursing. 

Wet-nurses with Goiter. — Bezy, of Toulouse, considers the question: 
Should women affected with goiter be accepted as wet-nurses ? He does not 
think so because there is a certainty of danger for the infant, but because it 
is more prudent to exclude such women from nursing. In 1897 he saw a 
fatal case of tetany in an infant aged six months in which no cause could 
be found for the disease except the fact that the mother who nursed this 
baby had exophthalmic goiter. A few months later he saw another case of 
the same kind, and in 1898 he saw a case of tetany in an infant aged three 
months, who died after an illness of about forty days and whose nurse had 
simple goiter. The author thinks that tetany in infants may be of thyroid 
origin, and that the thyroid affections of the nurse are transmitted to the 
nurslings. He does not pretend to establish an invariable law, but simply 
wishes to call attention to the possibility of such transmission and to suggest 
further investigations on the subject. 

We should reject a wet-nurse as unfit for nursing if she has : — 



82 IXFAXT FEEDING. 

1. Enlarged cervical glands. 

2. A goiter. 

3. Diseased lungs, no matter how trivial. 

4. Evidences of syphilis, such as condylomata, present. 

5. Condylomata on her genitals. 

6. Mastitis. 

7. Carious teeth. 

Eecurring menstruation is no contraindication for a wet-nurse. Some 
women are perfectly healthy and will menstruate regularly during their 
period of wet-nursing, without harm to the infant. 

Erosions or fissures on the nipple should not be looked upon as contra- 
indications for wet-nursing. Infants will thrive, although changed from 
one wet-nurse to another. Breast-milk is not uniform in its consistency. 
We know that its ingredients not only change from day to day, but that the 
milk varies several times a day. In spite of this fact children thrive, as 
was demonstrated by Schlechter, who used 400 children in tlie Vienna 
Foundling Asylum. Among these an epidemic of gonorrhoeal ophthalmia 
developed, requiring isolation. Thus, several nurses were ordered to be 
isolated with these infected children, and it was noted that these children 
developed just as well in spite of the change from their previous breast-milk. 

The mortality in this same institution resulting from feeding with 
sterilized milk has been entirely done away with since the introduction of 
wet-nursing. 

Finally, it is important to note that it is the quality of milk, rather 
than the quantity, which determines the value of breast-milk. 

When children are strong and well-built, and have a ravenous appetite, 
they require a slow-flowing br east-milk, as a rapid flow of breast-milk, aided 
by a hearty appetite, will tend to overload the stomach, and is one of the 
reasons for dyspepsia in young children. 

It is a good point to try to secure a wet-nurse suckling a child about as 
old as the one we wish her to nurse, although it is quite common to find 
nurses who have older children than the one they wish to nurse, and to find 
the latter doing well. 

The proof of the usefulness of the wet-nurse is the condition of the baby 
after some time. If the child thrives it will increase in weight. Hence 
scales must be frequently used. The milk should be examined by a chemist 
to determine the percentage of ingredients. 

Especial note should be made of the percentage of fat and proteids. 

If a very quick examination is required, then a microscopical examina- 
tion of one drop of middle-milk will show the character of the fat globules. 

The rough method of examination is useful when the life of the infant 
is at stake and it is necessary to determine quickly whether or not a given 
wet-nurse is suitable for an infant. If a baby suddenly appears colicky or 



INABILITY TO NURSE. 83 

does not gain in weight while wet-nursing, then a chemical examination of 
the breast-milk is imperative. We ran frequently find an excess of fat or, 
more often, an excess of proteids as the cause of eolie. 

Von Bunge presents the results of an investigation in which he shows 
that the increasing inability of mothers to nurse their infants is a matter 
of inheritance. He obtained information relative to 665 cases with the 
following result : The daughter was able to nurse her offspring in 182 cases. 
The mother was able in 99.2 per cent., and unable in only. 0.8 per cent. 
The mother was able in 237 eases. The daughter was able in 58.2 per cent., 
and unable in 40.8 per cent. The daughter was unable to nurse her off- 
spring in 483 cases. The mother was able in 43.2 per cent., and unable in 
56.8 per cent. The mother was unable in 147 cases. The daughter was 
unable in 99.3 per cent., and able in 0.7 per cent. 

He concluded from the foregoing figures that inability to nurse is 
largely a matter of inheritance. Further inquiries also led him to believe 
that tuberculosis and nervous diseases were to a considerable extent asso- 
ciated with inability to nurse one's offspring. But much more prominent 
appears to be the relation of intemperance. AYhere the mother and daughter 
were both able to nurse he found that the fathers were usually at least mod- 
erate in the use of alcohol, and only in 4.5 per cent, were they hard drinkers. 
On the other hand, when the mother was able to nurse, but the daughter 
was unable, it was found that the father was often intemperate, and in 46.8 
per cent, was an actual drunkard. In this inquiry the author considered 
those only as able to nurse who could nnrse all their children for a period 
of nine months. All others as unable. 

The control of wet-nurses was very adequately discussed 1 as a public 
prophylaxis. Many believed it was a matter that could be brought under 
the control of the law. 

Dr. Petrini, of Galatz, professor at the University of Bucharest, pre- 
pared an elaborate report in which the prevalence of infection of syphilis by 
means of wet-nurses was demonstrated. He showed that its frequency varied 
widely in different countries, and hence an English view, for instance, of its 
comparative importance, drawn from the rarity of the infection in that 
country, was not a criterion for the whole, since it had been shown for 
Oriental lands, and even for Paris, that it was an important element. 

He proposes a special medical service, working in co-operation with 
municipal authorities and having for its head a competent syphilographer. 
All children being nursed by wet-nurses should be inspected regularly by 
representatives of this bureau, and all wet-nurses should receive authoriza- 
tion for their calling by the same bureau after rigorous medical examina- 
tion. Special provision should be made for syphilitic children. 



1 Second International Conference for the Prevention of Syphilis and Venereal 
Diseases, held at Brussels. Belgium, Septemher 1 to 0, 1902. 



84 INFANT FEEDING. 



Clinical Illustrations or the Variations in Wet-nurses' Milk. 

The following case will illustrate the peculiarity of breast-milk in a 
wet-nurse : — 

Case I. — First examination of breast-milk showed: — 

Fat 2.50 

Milk-sugar 6.50 

Proteids 1.93 

Mineral matter 0.21 

Total solids 11.14 

Water 88.86 

When the wet-nurse was first employed, the infant gained more than eight 
ounces each week. Had yellowish stools, one or two each day. Slept well after 
nursing and appeared satisfied. Cried only at feeding time. No evidence of colic. 

A second examination of the breast-milk was made to compare the character of 
the milk with that of the first specimen: — 

Fat 2.10 

Milk-sugar 6.50 

Proteids 1.41 

Mineral matter 0.15 

Total solids 10.16 

Water 89.84 

Two months later, same wet-nurse. Child's weight stationary. Green, curded 
stools, cries and has colicky pains. Restless at night. Wet-nurse is menstruating. 
Chemical analysis of milk shows: — 

Fat 0.65 

Milk-sugar 6.50 

Proteids 1.12 

Mineral matter 0.11 

Total solids 8.38 

Water 91.62 

With the aid of cereals and malt, also a change from the city to the seashore, 
the milk improved. The infant was more satisfied. The stools again assumed a 
yellowish color. One month after this building-up treatment, an analysis of the 
breast-milk showed: — 

Fat 3.50 

Milk-sugar 6.50 

Proteids , 1.90 

Mineral matter 0.19 

Total solids ' 12.09 

Water 87.91 



VARIATIONS IN BREAST-MILK. 85 

When the infant was eight months old the secretion of milk was scanty, so 
that the breast was alternated with bottle-feeding. The general condition improved. 
The child was again satisfied. A chemical examination of the breast-milk showed: — 

Fat 3.00 

Milk-sugar 6.50 

Proteids 1.08 

Mineral matter 19 

Total solids 10.77 

Water 89.23 

As the proteids were found to be very low, I ordered the white of a raw egg, 
soup, and expressed beef juice. When the child was nine months old it was neces- 
sary to wean it, as the wet-nurse had very little milk. 

In this case the stationary weight, the colicky condition, and the char- 
acter of the stools were important guides, and fully agreed with the analyses 
of the specimens given. 

Case II. — Colic. — An infant five months old, suffered with severe colic. It cried 
continuously, especially after nursing. Relief was afforded when castor-oil was given 
or when warm colon flushing was resorted to. Diluting the breast-milk by giving 
an ounce or two of barley or rice water immediately after each nursing seemed to 
modify, but not altogether relieve, this condition. The chemical examination of 
the milk gave: — 

Fat 6.59 

Sugar 6.69 

Proteids 1.16 

Ash 19 

Total solids 14.63 

Water 85.37 

The excessive amount of the fat was evidently the cause of the trouble. The 
quantity of meat was reduced. Exercise was ordered and beer forbidden. In a few 
weeks the percentage of fat in the milk was greatly reduced, and the infant far 
more comfortable. 

Oao 



o°o%o *•?<& O 



On ° CJ £ 






°°aO o& o oo 
o o 



Case III. — Fig. 31. — Specimen of Breast-milk Taken from a Wet-nurse during 
Menstruation, Illustrating the Poor Character of the Emulsion. (Original.) 



86 INFANT FEEDING. 

The infant was very restless, and had colicky attacks. Note the small, un- 
evenly divided fat globules — irregular form of the larger globules. It appears to 
be a very watery emulsion. Chemical examination of the specimen showed: Fat, 
1.60; sugar, 6.50; proteids, 2.43. The baby did not gain during the whole week. 

Case IV. — Good Milk in a Wet-nurse. — In this case we have a child that was 
gaining in weight. Appeared satisfied after nursing, but had a tendency toward con- 
stipation. A chemical analysis of the milk gave: — 

Fat 4.20 

Sugar 6.50 

Proteids 2.80 

Ash 28 

Total solids 13.78 

Water 86.22 

Diet of a Wet-nurse. 

The diet given for a nursing mother can also be used as a guide in 
choosing the diet for a wet-nurse. The greatest care, however, must be 
bestowed on the manner of living. 

Manner of Living. — A wet-nurse that was a former servant, or worked 
out of doors, and is suddenly taken into this new mode of life and given 
charge of a baby, must have proper exercise. Otherwise she will very soon 
secrete milk which will be totally unfit for an infant, and as a result the 
child will probably have severe colic and irregular, cheesy stools ; will vomit 
excessively, and will not gain sufficiently in weight. It is therefore impor- 
tant to try and adapt a wet-nurse to the same condition as existed prior to 
her pregnancy; so that both her manner of living and, chiefly, her diet, 
shall not be different. 

That alcohol may be eliminated from milk is shown by a case reported by Val- 
lani. A nursing infant was seized with convulsions with great regularity on Mon- 
day and Thursday, but was quite well on other days. Investigation showed that 
the wet-nurse on Sundays and Wednesdays (her days out) was in the habit of drink- 
ing freely of alcohol. The curtailment of these privileges resulted in the disappear- 
ance of the convulsions. 

Proper Rest. — To be equal to her task a nurse must be given plenty 
of sleep, if it is at all possible. 

Adriance, in the Archives of Pediatrics, says : 

1. Excessive fats or proteids may cause gastro-intestinal symptoms in 
the nursing infant. 

2. Excessive fats may be reduced by diminishing the nitrogenous ele- 
ments in the mothers diet. 

3. Excessive proteids may be reduced by the proper amount of exercise. 

4. Excessive proteids are especially apt to cause gastro-intestinal symp- 
toms during the colostrum period. 



METHOD OF CHANGING THE INGREDIENTS IN WOMAN'S MILK. 87 

5. The proteids, being higher during the colostrum period of prema- 
ture confinement, present dangers to the untimely-born infant. 

6. Deterioration in human milk is marked by a reduction in the pro- 
teids and total solids, or in the proteids alone. 

7. This deterioration takes place normally during the later months of 
lactation, and unless proper additions are made to the infant's diet, is 
accompanied by a loss of weight or a gain below the normal standard. 

8. When this deterioration occurs earlier, it may be the forerunner of 
the cessation of lactation, or well-directed treatment may improve the condi- 
tion of the milk. 

Methods of Changing the Ingredients in Woman's Milk. 

Eotch gives a condensed table for these changes as follows: — 

To Increase the Total Quantity. — Increase the liquids in the mother's 
diet, especially milk (malt-extracts may be helpful), and encourage her to 
believe that she will be able to nurse her infant. 

To Decrease the Total Quantity. — Decrease the liquids in the mother's 
diet. 

To Increase the Total Solids. — Shorten the nursing intervals, decrease 
the exercise, decrease the proportion of liquids, and increase the proportion 
of solids in the mother's diet. 

To Decrease the Total Solids. — Prolong the nursing intervals, increase 
the exercise, and increase the proportion of liquids in the mother's diet. 

To Increase the Fat. — Increase the proportion of meat in the diet. 

To Decrease the Fat. — Decrease the proportion of meat in the diet. 

To Increase the Proteids. — Increase the exercise up to the limit of 
fatigue for the individual. 

It is wise in all cases of disturbed lactation, whether in maternal or 
wet-nursing, to make efforts in accordance with these rules to produce a mi 7 k 
that is suitable for an infant who is not thriving, before changing to any 
other method of feeding. 

Wet-nursing. 

It is an established fact that the best possible food for an infant is 
breast-milk. Where the mother of an infant is prevented from nursing 
her child, the next thing to be considered is wet-nursing. That nursing a 
child is an advantage to the mother is a well-known fact, inasmuch as it 
influences the contraction of the uterus and stimulates the circulation. 
Contrary to the belief that nursing a child is detrimental and contraindi- 
cated in women whose lungs are weak and who have a tendency to tuber- 
culosis, it does them no harm, and, indeed, seems to do them good. This 
statement is borne out by the experience of Dr. Heinrich Munk, of Karls- 
bad, Austria, a specialist in the diseases of women. 



88 INFANT FEEDING. 

Iii Austria the state supports public institutions for lying-in women. 
They are kept there and confined gratis, and remain about fourteen days. 
They are admitted into these hospitals in the last months of pregnancy. 
Vienna usually has about 300 women on hand. Prague constantly has 100 
women in this condition, who are utilized for the purpose of instruction to 
physicians and midwives. 

In Prague there are about 3000 women confined annually, and these 
women are put into the foundling asylum. There they remain until they 
procure a place as a wet-nurse or as long as their services are needed in the 
asylum. When wet-nurses are taken from the foundling asylum, it is a 
frequent occurrence to have those remaining therein nurse at least two chil- 
dren, and frequently three, at one time. In this manner they dispense grad- 
ually with these wet-nurses without hurting the remaining children. Many 
children die, some of them intrapartum in operative confinements, and the 
women (mothers of such children) are then utilized, for wet-nursing. It 
is a rule to keep the children in the asylum until they have attained a little 
over -1 kilograms (about 9 pounds), and they are then put out for further 
feeding (artificial feeding), for which the city pays about 12 florins ($5.00) 
a month. The children remain usually until they are 6 years old, and are 
then given back to their own mothers. Many of these children die; others 
are adopted by those who have reared them, but the greater portion are 
taken back to their own mothers. In Vienna there are about 10,000 con- 
finements annually in the public institution. There are a great many cities 
in Austria — like Innsbruck-Olmutz, Brunn, Linz, and Klagenfurt — where 
there are at least 200 confinements annually. In A^ienna a wet-nurse receives 
30 florins per month, for which she is sent (railroad expenses paid) to 
whoever requires her services. She is taken on trial for fourteen days to see 
if she is adapted for her place. A wet-nurse can be procured by sending a 
telegram and a money order any day during the year. The customary wages 
are from 12 florins upward per month. Each wet-nurse is carefully exam- 
ined by the professor before she is sent away. A great many families do 
not care to take a wet-nurse from an as}dum, as they are usually women of 
the lowest walks of life, and they prefer, therefore, to take a woman who 
has been married. For this purpose agencies, duly licensed, exist. These 
will supply wet-nurses, and usually take orders in advance; thus a wet- 
nurse may be reserved. Such Avet-nurses cost much more, and those from 
one special region — Iglau, in Mahren — receive from 20 to 50 florins monthly. 

The Empress took a wet-nurse from Iglau (a married woman), and 
the Princess of Bulgaria took a wet-nurse from Iglau for her last child. 
Not only Iglau, but the whole region, is renowned for its excellent quality 
of wet-nurses. The Bohemian and Mahren nurses have very good mammae. 
They seem to love the children entrusted to them. In America the wet- 
nurses are uneducated servants. 



WET-NURSING. 



89 



While it is a rule that a wet-nurse should be taken for a baby of the 
same age as that of her own, frequently wet-nursing of an infant at birth 
by a wet-nurse whose baby is three months old has not been followed by any 
bad results. 

In New York we are at a decided disadvantage regarding wet-nurses. 
As no licensed agents exist, a few people having so-called influence procure 
wet-nurses by friendship, or something similar, from superintendents and 
house physicians where obstetrical work is done. 

Thus we find ourselves at the mercy of some people who traffic in wet- 
nurses for a fee, usually five to ten dollars, and who do not stop at anything 
to attain their own selfish end. 




Fig. 32. — Pear-shaped Breasts, Best Adapted for Nursing. (Original.) 



Time and again have I sent for a wet-nurse to an agent who, instead 
of giving me a healthy wet-nurse, tried to induce me to use women having 
colostrum-milk for an infant in which such milk would have proved dis- 
astrous. 

In another instance, only recently, I procured a wet-nurse from an 
agent who sent me a girl .17 years old, who had had a premature birth, 
"evidently an abortion," and whose milk was thin and watery, with here 
and there a fat-globule when examined under the microscope. 

At other times some of the finest specimens of wet-nurses have been 
procured from the same agent. 

It is a pity that we have no municipal control for what the writer 
considers one of the most valuable adjuncts to our infant-feeding, and in 



90 INFANT FEEDING. 

the same manner such control would regulate the supply to such unlimited 
number that modern arrogance on the part of the wet-nurse would probably 
disappear. 

The prices paid in New York are from $20 to $30 per month and board, 
and this price prohibits many an infant from securing the benefits of 
Nature's food. Let us hope for municipal regulation. 

Weaning and Feeding from One Year to Fifteen Months. 

Weaning should take place gradually between the eighth and tenth 
months. In some instances it is advisable to commence weaning a child 
mnch sooner; for example, when there is a deficiency in the supply of milk 
or owing to ill health of the mother. This I have already mentioned in the 
section on "Mixed Feeding." 

"Weaning is imperative when the infant's mother is pregnant, although 
it is advisable to use great caution if it occurs in midsummer. In a case of 
this kind the better way would be to have a specimen of the breast-milk 
examined by a chemist, and if the same be found deteriorated in quality, 
then the judgment of the physician must prevail as to the advisability of 
continuing or discontinuing the nursing. My rule has been not to wean 
during the summer months. 

The main points have already been mentioned in this chapter under 
"Wet-nurse." 

Weaning should not be attempted suddenly. It is better to commence 
weaning gradually by withdrawing the breast in the morning and substi- 
tuting the bottle for that meal. Following this meal we can again nurse 
the child at the breast for two more feedings, and substitute a bottle for 
its fourth meal instead of the breast. 

In this manner we can feed the infant with a bottle in the morning, 
to be followed in three or four hours by the breast, then at the next feeding 
again nurse the child, and this to be followed in three or four hours by the 
bottle :— 

8.00 a.m Bottle. 

11.30 a.m Nursing. 

3.00 p.m Nursing. 

6.30 p.m Bottle. 

10.00 p.m Nursing. 

Thus we can see just how the food is assimilated, and also study the 
individual peculiarities of the baby. Some children are very hard to wean, 
and it will require great tact and patience to successfully cope with this 
condition. 



1 



WEANING. 



91 



Cask T. — Difficult Weaning. — A child, seventeen months old, had greenish stools, 
and did not thrive. His body weight was stationary. He was restless both day 
and night. He was nursed every two hours and cried when the nipple was taken 
away. The chemical examination of the breast-milk showed about one per cent, of 
proteids and less than two per cent, of fat. 

In this case the prolonged lactation was unsatisfactory. The wet-nurse was 
ameniic. and consequently her milk was poor. I ordered weaning from the breast. 
The child refused to take food by spoon or cup and would spit whenever food was 
forced into his mouth. Tt was necessary to place the child in charge of a trained 
nurse and remove the wet-nurse entirely from the baby. I ordered gavage with 
equal parts of milk and rice water. Six ounces were given at one feeding, every 
four hours. After two days of continued forced feeding (gavage) the child took 
some milk, and also soup from a cup. 

Case II. — I was called to see a perfectly healthy child about nine months old, 
whose mother told me that "Her child would not take the breast." She w T as greatly 
chagrined, but all efforts at nursing him proved futile. The infant had weaned him- 
self. Such cases of "self-weaning" are very rare. 




Fig. 33.— Ideal Feeding Cup. 

When weaning is successfully accomplished, then great care must be 
exercised owing to the change in diet. It will be found that the slightest 
error in overfeeding or too frequent feeding will be rewarded by a severe 
attack of dyspepsia and the usual gastric disturbances, such as vomiting 
and fermentation in the stomach, causing diarrhoea and, possibly, colic. 
It will therefore be very necessary to exercise good judgment in the 
choice of both quality and quantity of food during the first month or two 
after weaning, or until the stomach adapts itself to this new way of 
feeding. The amyhlytic function now being thoroughly developed, we can 
safely give cereals. I prefer a saucer of farina steamed at least two hours. 

Time of Feeding. — Excepting in rare instances, after a child is 
weaned it should not be fed oftener than once in four hours. The best 
time for feeding would be about G a.m., 10 a.m.. 2 p.m., G p.m., and 10 p.m., 
if the child is awake. This would give eight hours' rest. 



92 INFANT FEEDING. 

The first bottle after sleeping should consist of 8 ounces of pure 
cow's milk. This would be the G a.m. feeding. 

Tour hours later, or at 10 A.M., the infant should receive the white of 
a raw egg with 

Cows' milk 5 ounces 

Barley water 3 ounces 

Granulated sugar 1 level teaspoonful 

At 2 p.m. our feeding should consist of 8 ounces of pure cows' milk. 
I usually permit the infant to nibble on one-half piece of ordinary 
zwieback. 

The evening meal at 6 p.m.: — 

Cows' milk C ounces 

Barley water 2 ounces 

Granulated sugar 1 level teaspoonful 

The last feeding, at 10 p.m. if the child is awake, or at midnight, 
should consist of 8 ounces of pure cows' milk. 

When milk is brought from the dairy there is a thick layer of cream 
on the top which should be thoroughly mixed with the milk by shaking 
the bottle, so that the infant receives a thoroughly mixed milk con- 
taining the same quantity of cream in each feeding. The milk should be 
mixed and the barley water added to it. It is then poured into thor- 
oughly cleaned bottles, which are stoppered with ordinary cotton stoppers. 
This can be found described in detail in the chapter on "Sterilization." 
This food is to steam for twenty minutes and then allowed to cool by 
placing the bottles in a refrigerator, but not on the ice. "When ready for 
use each bottle is to be warmed to a temperature of 100° F. for the feed- 
ing. If constipation follows the use of this diet, then a good plan is to 
substitute 2 ounces of oatmeal water instead of the barley water above 
mentioned. When the stools are regular but the child appears to be 
quite pale, then great good can be accomplished by adding 2 ounces of 
almond-milk instead of the oatmeal or barley water. The preparation of 
almond-milk can be found described in the "Dietary," to which I beg to 
refer my readers. If a severe form of constipation, with cheesy curds in 
the stools, exists, then the milk should not be steamed, but fed in the 
"raw state." It is to be understood that it should be warmed to the body 
heat, before feeding to the infant. Instead of giving the white of egg 
every day I substitute either 1 or 2 ounces of beef soup, chicken soup, 
beef tea, or expressed steak juice, and feed this quantity immediately 
before the 10 a.m. bottle of milk. Xo distinct change of food is neces- 
sary until the child is twelve or fifteen months old, when I am in the 
habit of giving either a half-saucer of oatmeal gruel, farina, barley, or 
hominy and butter, in addition to a morning bottle. When the child 



MANAGEMENT OF WOMAN'S NIPPLES. 93 

arrives al this age a half-dozen teaspoonfuls of junket can be tvd before 
the evening bottle of milk. When a child is over one year or about fifteen 
months old, instead of giving water for thirst I frequently give prune- 
water made by boiling good, fleshy prunes in water for one-half hour and 
straining off the liquid. When oranges can be procured, one or more 
fcablespoonfuls of juice can be given to advantage. Apple sauce can also 
be given. Thus my plan consists in giving one of these foods on different 
days. Just at this period the addition of several teaspoonfuls of Eskay's 
food has been found very beneficial. Owing to gastric derangements, it 
will be found necessary to frequently discontinue milk entirely. At suck 
times the use of the milk foods, such as Horlick's food and Nestle's food, 
has proved very beneficial. When diluting milk with cereals, like barley 
water, rice water, sago water, flour ball and water, it is always better to 
dextrinize the diluents. This dextrinization has a decided effect on the 
casein, inasmuch as it splits up the curd, rendering it finely floceulent as 
it is found in human milk, and it is especially indicated in the period of 
weaning after the stomach has been accustomed to breast-milk, and is 
suddenly forced to digest cows' milk containing a more tenacious and 
heavier casein, or curd. 

The Management of the Nipples Before the Baby is Born. — It is very 
important during the last few months of pregnancy to devote consider- 
able time and attention to the condition of the nipples. If these be found 
long and round, well projecting, then it is advisable to try to harden 
them, because the irritation from the child will cause considerable 
trouble unless we seek to prevent this. 

Oni, in treating the question of sore nipples, said at the Medical 
Society, 1 that one out of every two nursing women was affected with 
lesions of the nipples. The determining cause of the fissures was macera- 
tion of the epiderm under the double influence of the saliva of the infant 
and the milk which flowed during the intervals. The epiderm exfoliated 
and the derm exposed became excoriated ; the lesion thus produced became 
infected, and, instead of healing, progressed in extent. The predisposing 
causes were short and inextensive nipples and want of cleanliness. The 
primiparse were affected with fissured nipples to the extent of 59 per cent. 

The prophylactic treatment consisted in astringent lotions during 
pregnancy, while after delivery the nipple should be washed with boric 
acid lotion before and after suction, the application of an antiseptic 
dressing during the intervals of nursing. The curative treatment, to be 
radical, consisted in the suspension of nursing, which, although excellent 
for the mother, would be deplorable for the child. The list of agents 
employed against the fissure was very lengthy, indicating their uselessness. 



Paris Cor. Med. Press and Circular. 



94 INFANT FEEDING. 

In summer cold water will be found more agreeable, with a small quan- 
tity of alcohol. If the nipples are very, small and flat, and do not protrude 
properly, then suction by means of a breast-pump, applied directly over the 
breast, will draw them out. In some instances an ordinary clay pipe which 
has a smooth bowl, the bowl to be laid over the nipple and the stem to be 
sucked or drawn, is satisfactory. This is to be repeated every few days. 
A few minutes of drawing out will suffice until the nipples are sufficiently 
prominent. Biedert 1 gives the following prescription for hardening the 
nipples : — 

Tannic acid 1 teaspoonful 

Red wine 8 ounces 

If red wine is not handy, then substitute brandy in its stead. This is 
to be applied after thorough washing with soap and water, and removing 
crusts, if they are present. 




I 



Fig. 34. — Nipple-shield for Relief of Tender Nipples. 

Tender Nipples. — If, while nursing, the nipples crack and blood oozes 
from them, or if, from irritation of the child's gums biting them, the nipple 
is sore, then it is a good plan to allow the child to nurse through a nipple- 
shield. (See Fig. 34.) 

Nipple-shields can be used during the nursing act, and immediately 
thereafter the following salve can be smeared on the nipples : — 

fy. Zinc oxide 1 drachm 

Vaseline 1 ounce 

TREATMENT OF TENDER NIPPLES (gARRIGUES). 

^ Orthoform 1 drachm 

Lanoline 1 ounce 

M. Sig.: Apply. 

Breast-pump. 
The breast-pump (Figs. 35 and 36) is a valuable addition to the nur- 
sery. It should be kept scrupulously clean by immersing it in boiling water 



i " 



Kinderernaehrung," fourth edition, 1900, page 110. 



BREAST-PUMP. 



95 



containing a pinch of table-salt. In drawing a specimen of breast-milk for 
a chemical examination the breast-pump is very useful. If an infanl is ill 
and refuses the breast — as, for example, if il has rhinitis or cold in the head, 
nasal obstruction, preventing it from breathing while the nipple is in its 



mouth — it general 



ly will take the breast and immediately let go of it again. 




Fig. 35. — Breast-pump. 

If the breast-pump is properly applied, and the required quantity of milk 
drawn off, the infant can frequently be fed slowly with a spoon. 

In a serious condition — as, for example, in a seyere case of pneumonia 
with loss of appetite — the life of the child may depend on forced feeding. 
This will be described in the section on "Gayage." It is very important to 




Fig. 36. — Breast-pump. 

have the cup or any other receptacle into which we draw the breast-milk 
properly sterilized; otherwise the breast-milk will be infected in the same 
manner as has been described in detail in the sections on "Cows 5 Milk" and 
"Bottle-feeding." 



Massage of the Bkeast During Lactattox. 

Caking. — The "caking," or hardening, of the breast is not due to cur- 
dling of the milk. This neyer takes place within the milk-tubes, nor yet to 



96 IXFAXT FEEDING. 

the in'esence of milk, for as a rule no milk is formed, according to tfie writer, 
until nursing begins, or if any, but a very small amount. The hardening 
of the gland is due to the congestion of the blood and lymph, and therefore 
massage should be directed to the removal of these, and likewise should 
be centrifugal in direction, and not aim to the removal of the milk by centrip- 
etal stroking. The blood-supply of the gland is mainly derived from the 
subclavian and axillary arteries ; the venous outflow and the lymph discharge 
is by corresponding channels, and this is the anatomical basis for action. 
The massage should begin gently below the clavicle and in the axilla, and 
gradually encroach more and more on the mammary region. By this method 
a hard and painful breast is rendered lax and comfortable without the dis- 
charge of any milk. The writer does not recommend the treatment where 
there is infection or true inflammation, as in mastitis ; in such conditions 
rest is indicated, and nothing should be done which will tend to spread the 
infection. 1 



Proteid Ixdigestiox ix Xursixg Ixfaxts, Causixg Colic 
axd coxstipatiox. 

1. Colic. — One of the most frequent disorders in nursing infants is 
colic. This colic usually appears about one hour after nursing. Sometimes 
it appears a little sooner; sometimes a little later. Associated with this 
colic is the usual evidence of pain. The attack appears in the following 
manner: In about an hour after nursing, the child, which up to this time 
has been quiet or asleep, will suddenly awake with a shriek and scream. At 
the same time it will draw the legs on the abdomen, get very red in the face, 
and continue to scream for a few minutes. Such an attack will last from 
fifteen to twenty minutes; at other times as long as one hour. Belief is 
usually afforded by gently rubbing the abdomen with warmed sweet-oil or 
vaseline; in other words, by using gentle massage. Besides the oil, an 
enema, consisting of warm water and glycerine, or warm chamomile tea, 
usually affords relief by removing the offending and undigested casein. 
The stool will usually be found to contain large quantities of undigested 
cheese. Small white particles can be seen scattered through such stool. 

It is not uncommon to find, where such a condition exists, that the 
attacks will appear after each nursing. A distinct association between the 
condition described and the nursing must be suspected. When this condition 
is suspected, then the milk must be examined by a chemist to determine the 
percentage of its ingredients. If the percentage of casein is found excessive, 
then exercise by the nursing mother will be called for. 



1 See an elaborate paper, on this subject by Bacon in American Journal of 
Obstetrics. 



PROTEID [NDIGESTION CAUSING COLIC AND CONSTIPATION. 



97 



Sometimes reducing the nitrogenous food and drinking large quanti- 
ties of liquid, will modify the amount of caseine, so that the milk will not 
be so concentrated, [f the child continues with this colicky condition, then 
we must instruct the mother regarding exercise. It is well to give the infant 
a small quantity of oatmeal water; several teaspoonfuls will suffice after 
each nursing. In other instances giving the baby small quantities of pan- 
creatine, or a combination like the Fairchild's peptonizing powder, will be 
found advantageous. This can be given so that we peptonize the food and 
aid in the digestion and assimilation of the same. 

We are dealing with mother and infant, and a great many changes will 
be demanded. Care should be bestowed upon the condition of the mother's 
bowels. The slightest constipation should be modified by giving her a 
saline. A teaspoonful of Epsom salts in the morning, repeated in the even- 
ing if necessary. 

She should eat large quantities of fruit, such as peaches, prunes, grapes, 
apples, and oranges. 

2. Constipation. — Another result of proteid indigestion is constipation. 
When we are told that large, dry, cheesy curds are evacuated, then the cause 
of such indigestion should be sought. 

If the infant is nursing, the proper method to pursue is to examine a 
specimen of breast-milk under a microscope, using the middle milk for this 
purpose. Submit a specimen to a chemist or to a laboratory and note the 
percentage of ingredients. 

If there is a deficiency in the percentage of fat, such deficiency can be 
remedied by giving the baby an equivalent of cream. If there is a deficiency 
of carbohydrate, we increase the same by giving the baby some sugar. When 
there is proteid deficiency we can modify the same by adding raw r albumin 
(white of egg) or almond milk, pea soup, lentil soup, or broth made of meat. 

The above will give a choice between animal or vegetable proteids. 

Infant Mortality and a Study of the Mode of Feeding. 



Table No. 16. — Registrar General — England and Wales, 1890-94. 



Year. 


Total 
Births. 


Total 
Deaths. 


Deaths Under 
1 Year. 


Deaths from 
Diarrhoea. 


Deaths from 

Diarrhoea 

Under 1 Year. 


1890 

1P91 

1892 

1893 

1891 


869.937 
914,157 
897,957 
914,572 
890,289 


562,248 
587.9-25 
559,684 
569,958 

498,827 


130,955 
135,801 
132,463 
145,061 
121,799 


17,837 
13,962 
15,336 
29,721 
10,763 


11,795 

9,200 

10,487 

20,722 

7,360 



98 



INFANT FEEDING. 



Table No. 17. — Mortality Table for London, 1890-94- 



Year. 


Total 
Births. 


Total 
Deaths. 


Deaths Under 
1 Year. 


Deaths from 
Diarrhoea. 


Total Under 
1 Year. 


1890 

1891 

1892 

1893 

1894 


128,161 
134.484 
132,328 
133,062 
131,454 


87,689 
89,122 
86,833 
89,707 
75,635 


20,944 
20,776 
20,441 
21,814 
18,812 


2,823 
2,496 
2,642 
3,546 
1.771 


1,983 
1,829 
1,884 
2,601 
1,324 



Table No. 18. — Deaths Due to Diarrhoea and Mode of Feeding {Cameron). 





Cases 
Investigated. 


Percentage of the 153. 


Age in Months. 


On Breast 
Only. 


On Breast 
Partially. 


On Bottle. 


0-3 

3-6 


41 
55 
34 
23 

153 


24 

16 

3 

30 

18 


20 

13 

9 

17 

14 


56 
71 


6-9 


88 


9-12 


52 




68 



Erdss collected statistics from sixteen cities of Europe, and found that 
of 1,439,056 children born there died 130.610 during the first four weeks 
of their life, or nearly 10 per cent. 



Table No. 19. — Two Hundred Deaths — Their Mode of Feeding (Louis Fischer). Inquiry 
into 200 Deaths, Taken at Random at the Children's Service of the German Poliklinik 
and West Side German Dispensary. 



Age in Months. 


Cases 
Investigated. 


On Breast 
Only. 


On Breast 
Partially. 


Bottle Feeding 
Only. 


0-3 

3-6 ..... 

6- 9 

9-12 


78 
30 
64 
28 

200 


5 

7 

12 

9 

33 


8 
12 
16 
12 

48 


65 
11 
36 

7 

119 



The above children were inhabitants of both the East and West Side 
of Xew York City, living in crowded apartments. The hygienic factor is, 
therefore, an important one. Sixty per cent, of these children died from 
gastric and intestinal disease. About 30 per cent, died from catarrhal dis- 
eases affecting the air passages, such as bronchitis, pneumonia, and tuber- 
culosis. The rest died from infectious diseases and surgical accidents. 



CHARTER II 



cows- }III.K. 



Hamiiersten 1 gives the following analysis of cows' milk in a thou- 
sand parts as follows: — 

Water 874.2 

Solids 125.8 

Fat 36.5 

Sugar 48.1 

Salt 7.1 

Proteid (casein, 28.8; albumin. 5.3) 34.1 

A. Baginsky 2 gives the following analysis of cows' milk, made at the 
Kaiser and Kaiserin Friedrich Hospital, Berlin : — 

Water 87.60 

Solids 12.38 

In one hundred parts. 

The solids consist of : — 

Casein and albumin 3.65 

Butter 3.11 

Milk-sugar 4.54 

Inorganic salts 1.08 

Besides large amounts of potassium and potassium salts and small 
quantities of iron. 

Composition, Variation, and Production. — Milk of all animals, roughly 
speaking, is composed of the same ingredients, but an analysis of milk is 
apt to he very misleading, as it does not show the physical condition of the 
milk, which is the important thing to know, from the physician's standpoint. 

The general ingredients of milk are fat, sugar, albumin, casein, salts, 
and water. These ingredients vary in quantity from day to day, and from 
milking to milking. An average analysis of a woman's milk does not show 
what an infant is getting, by any means, for the composition of the milk 
depends upon the food, the health of the mother, and the frequency of 
nursing. 

The Breed of a Cow. — Some breeds yield quantity; others quality. 
Holsteins produce the most milk ; Alderneys and Jerseys yield the most 
fat; Shorthorns give the most casein and sugar. The average capacity of 
a cow's udder is about 5 pints, and the annual yield of milk is about 600 
gallons. 

1 "Physiological Chemistry." 

2 "Diseases of Children," 1S09. page 32. 

(99) 



100 INFANT FEEDING. 

Time and Stage of Milking. — Cows are usually milked twice a day, 
the morning milk usually being larger in quantity and poorer in quality. 
The milk which is first drawn is known as the fore-milk, and contains very 
much less fat than that last drawn, known as the strippings. This is due 
to a partial creaming taking place in the udders. Dishonest dealers have 
often taken advantage of this fact in adulteration cases to have the cows 
partially milked in the presence of ignorant witnesses, the resulting milk 
consisting largely of the fore-milk. 

Age of Cows. — Young cows give less milk, while cows from four to 
seven years old give the richest milk, and less milk is given with the first 
calf. They give the largest yield, according to Fleishmann, after the fifth 
until the seventh calf; after the fourteenth calf they yield, as a rule, no 
more milk. The poorest milk is yielded during the spring and early sum- 
mer ; the richest during the autumn and early winter. If cows are worried 
or driven about, the quality and quantity of the milk are reduced. If they 
are kept warm and well fed, both quantity and quality are naturally in- 
creased. 

According to Eotch, the Durham, or Slwrtliorn, represents the best type 
of cow for this purpose. She has great constitutional vigor, great capacity 
for food, a perfect digestion, and, most important of all, a quiet tempera- 
ment. The analysis of her milk is as follows: — 

Per cent. 

Fat 4.04 

Sugar 4.34 

Proteids 4.17 

Mineral matter 0.73 

Total solids 13.28 

Water 86.72 



100.00 



The Devon- is another breed of cow having the same characteristics as 
the Durham. They are gentle and vigorous, and yield a large quantity of 
rich milk, the analysis of which is as follows : — 

Per cent. 

Fat 4.09 

Sugar 4.32 

Proteids 4.04 

Mineral matter 0.7G 

Total solids 13.21 

Water 86.79 



100.00 



COWS' MILK. 101 

The Ayrshire, another type, while representing strength, is somewhat 
nervous, and while not as hardy as the Durham, they are free from disease 
and yield a Large quantity of milk, the analysis of which is as follows: — 

Per cent. 

Fat 3.89 

Sugar 4.41 

Proteids 4.01 

Mineral matter 0.73 

Total solids 13.04 

Water 86.96 



100.00 



The Holstein-Friesian, commonly called Holstein, represents the most 
perfect type of cow. She yields a large quantity of milk, though light in 
its total solids. The following is the analysis : — 

Per cent. 

Fat 2.88 

Sugar 4.33 

Proteids 3.99 

Mineral matter 0.74 

Total solids 11.94 

Water 88.06 



100.00 



Some of the marks which distinguish the breeds of cows best adapted 
for infant feeding are : — 

1. Constitutional vigor. 

2. Adaptability to acclimatization. 

3. Xotable ability to raise their young. 

4. Freedom from intense inbreeding. 

5. A distinctly emulsified fat in the milk. 

6. A preponderance in the fats of the fixed glycerides over the vola- 
tile glycerides. 

The volatile glycerides do not exist in the mammae, but are formed 
in the milk soon after milking. In some breeds, as in those of the Channel 
Islands, this change occurs more quickly than in others. Such breeds, as the 
Jersey, Guernsey, and any others in which intense inbreeding has been car- 
ried on, and in which acclimatization has not been perfected, should not 
be used for infants and young children. These breeds, of course, do not 
represent all of those available for substitute feeding, for we may mention 
many others equally good each in its country. For example, the Kerry, 
of Ireland; the Red Polled, of England; the Dutch Belted, and the Flem- 
ish; also, the Flamandc and the Cotentine. of France; the Norman breed, 



102 INFANT FEEDING. 

of Normandy ; besides the Sirmenthal, sometimes called Bernese, of Switzer- 
land; together with the Chianina, of Italy, and the Allgauer. of Germany. 
The native cow of this country, the "Red Cow." through many generations 
of neglect and exposure in winter, has undoubtedly acquired an impaired 
digestion, and does not respond readily to appropriate changes of food. 

Care of the Cow. — Knowing the cow to be a sensitive animal, she 
should be carefully guarded from useless excitement. She should be care- 
fully groomed by cleaning and washing, and the parts should be thoroughly 
dried. The barn should have plenty of fresh air, and the sunlight should be 
admitted. There should be plenty of room for exercise. In the stalls the 
cow should "have perfect freedom for her head and limbs. The food a cow 
receives should be wholesome and varied. She should never be fed with the 
by-products of brewery or glucose factories. The food best adapted for the 
cow is hay, wheat, bran, ground oats, and cornmeal. In winter sugar beets 
and carrots may be added. Much care is needed to graduate the change from 
green foods to dry. as disturbance of the equilibrium of the mammary 
gland is followed by injurious effects to the consumer. We should strive 
to give a cow green clover, green corn, green oats, and meadow grass. Poi- 
sonous weeds must be guarded against. Xot infrequently we read of gastro- 
enteric conditions in children, which are traceable to poisonous weeds. Pure 
water in large quantities must always be at hand. A cow is best adapted 
for the production of milk between her third and ninth years. The milk 
of a cow is not adapted for infant feeding until it is free from colostrum 
corpuscles. It should not be used in the advanced stage of pregnancy. 

Tuberculin Test. — Every dairy now resorts to prophylactic measures: 
hence, none should be employed that has not been subjected to the tuber- 
culin test. Besides this, each cow should be examined by a skilled veteri- 
narian regarding her physical condition. 

Care of the Mill-. — The vital point consists in excluding germs and 
barn filth. The Milk Commission of New York has tentatively fixed upon 
a maximum of 30.000 germs of all kinds per cubic centimeter of milk. A 
cubic centimeter is about one-half a teaspoonful^ and a quart of milk con- 
tains about 900 cubic centimeters, so the total number of germs in a quart 
must be less than 27,000,000. 

This standard must not be exceeded in order to obtain the endorsement 
of the Commission, and must be attained solely by measures directed toward 
scrupulous cleanliness, proper cooling, and prompt delivery. 

Furthermore, the milk certified by the Commission must contain not 
less than -1 per cent, of butter fat. on the average, and have all other 
characteristics of pure, wholesome milk. 

In order that dealers who incur the expense and take the precautions 
necessary to furnish a truly clean and wholesome milk may have some suit- 
able means of bringing these facts before the public, the Commission offers 



CERTIFIED MILK. 10o 

them the right to use caps od their milk jars stamped with the words: 
"Certified by the Commission of the Medical Society of the County of New 
York." 

Rowland G. Freeman, answering an inquiry of mine concerning the pos- 
sibility of procuring milk Tree from genus in the dairy, says: "'By means of 
special methods it has been found possible in some cases to obtain milk 
with only 10 bacteria per cubic centimeter. These methods are. however, 
not practicable for a large commercial supply. When the conditions at the 
dairy are known to be good a bacterial content averaging less than 5000 
per cubic centimeter has seemed to me satisfactory, while a bacterial content 
averaging less than 10,000 is fairly good." 

Thus it appears, that with excellent care, as described in the handling 
of milk, with modern hygiene, practically sterile milk can be procured for 
infant feeding. 

Certified Milk ix Xevt York. 

The dairy rules of the United States Department of Agriculture de- 
scribe in detail the caring and feeding of cattle. It was decided that the 
acidity of milk should not be higher than 0.2 per cent., and that the num- 
ber of bacteria should not be more than 30,000 per cubic centimeter. 

The Rockefeller Institute for Medical Eesearch inaugurated a periodical 
inspection of the dairies and milk of the dealers who were willing to co- 
operate to secure a clean, fresh milk. 

It was observed that the milk from a cow milked in a dirty barn showed 
120,000 bacteria to the cubic centimeter, while another cow of the same 
herd milked in a pasture gave milk with only 26,000. A cow standing near 
a pile of dry feed had 1,000,000 bacteria per cubic centimeter, while the 
milk of other cows had a low bacterial count. Dirty cows gave a much 
higher count of bacteria than clean ones. Clean cows in a herd gave a count 
of 2000 as against 90,000 in the milk of the dirty cows. The milker was 
frequently found to be dirty, and the milk from some milkers always gave 
a high bacterial count. With the utensils it was sometimes difficult to find 
which factor was at fault. The ordinary strainer was, however, a prolific 
source of bacteria. 

With a sterile pail and a sterilized cotton or cheese-cloth strainer the 
bacteria would fall in numbers. Aeration by requiring more complicated 
apparatus increased the danger of contamination. This was particularly 
so if aeration was carried out in a dirty barn or without regard to strict 
cleanliness. 

The process of rapid cooling is one of the most important factors in 
the production of uncontaminated milk. The cooling of milk in springs 
is seldom sufficient, as the temperature of water in summer was found to 
varv from 45° F. t<> 70° F., whereas the milk should be brought below 45° F. 



104 INFANT FEEDING. 

to insure few bacteria. Ice is absolutely necessary to tlie farmer who 
handles milk. W. H. Park (Yale Medical Journal) says, as to the number 
of bacteria in the city milk: "From an examination of nearly 1000 speci- 
mens there is no question about the enormous number of bacteria present in 
the city milk. Xow as to the harmfulness of this milk : The group of chil- 
dren under 1 year, on heated milk, received from decent farms, running 
before heating from 1,000,000 to 5,000,000 bacteria per cubic centimeter, 
did not, so far as we could see, suffer any serious harm from the bacterial 
products in the milk. During the summer these children had, off and on, 
intestinal disorders, but not much more than those in the same section of 
the city receiving milk from the very best possible dairies around New York. 
The children on pasteurized milk showed some very interesting results. 

"There were very few bacteria in this milk when first received — any- 
where from 10,000 to 20,000; but on the second day they had so increased 
as to be from 10,000,000 to 30,000,000. In some cases where the second 
day milk was given there was immediate vomiting, followed by diarrhoea. 

''Bacteiial Count of Milk Bought in a Public Park During the Summer of 190-i. 
— One cubic centimeter of Strauss's sterilized, modified milk contained 22,624 bacteria. 
Growth of colonies was upon nutrient gelatine, and count was made thirty-six hours 
after growing the plate. 

"In the asylums, where the children were from 3 to 13 years of age, 
we found no trouble from the milk during the summer months, although 
in some cases it ran as high as 100,000,000 bacteria per cubic centimeter. 

"As controls, we watched infants in the hospitals and in the tenements 
taking breast-milk, and these not infrequently developed intestinal disorders, 
showing that Ave could not in all infants taking cows' milk attribute these 
disorders to the milk impurities. Altogether it seems that fairly numerous 
bacteria in milk obtained from clean, healthy cows living on good farms do 
not cause harm in the older children and the products do not cause much 
harm to younger children when subjected to heat. When milk contaminated, 
badly and improperly kept, so that the bacteria greatly multiply, is fed to 
babies, they do badly, and it seems that much of the mortality is due to 
poisonous conditions of the milk developed by the bacteria. 

"The reasons for the enormous development of bacteria in the milk were 
insufficient cleanliness in getting the milk and very faulty cooling arrange- 
ments. The farmers mostly put their milk in springs; as the summer 
advances the water gets higher in temperature until it reaches about 60° 
F. Some farmers hardly cool their milk at all. The author has seen milk 
shipped in cans standing in a car where the temperature was 90° F., and 
left there without any ice for seven hours. The City Health Board has 
passed a rule that all milk shall be at a temperature of 50° F., or under, 
when it reaches Xew York City. 



TUBERCULOUS [NFECTION THROUGH MILK. 



105 



'The Health Department found that milk from a decent farm properly 
cooled will not run over 100,000 bacteria per cubic centimeter at the end 
of twenty-four hours, and that such milk, if kept for two days at 45° F., 
will not run more than 200,000. Therefore, all milk that runs over 100,000 
bacteria per cubic centimeter has certainly not been kept in a proper con- 
dition, and such a number of bacteria indicates faulty methods of caring for 
the milk. The Health Board has passed a resolution saying that milk con- 
taining excessive numbers of bacteria is unwholesome and should not be sent 
to Xew York/' 

EXTRACT FROM THE "SANITARY CODE," DEPARTMENT OF HEALTH, 

City of Xew York, 11)01. 

'*Xo milk which has been watered, adulterated, reduced, or changed in 
any respect by the addition of water or other substance, or by the removal 
of cream, shall be brought into, held, kept, or offered for sale in the city 
of Xew York; nor shall any one keep, have, or offer for sale in the said city 
any such milk. 

"The term 'adulterated/ when used in this section, means: — 

"First. — Milk containing more than 88 per centum of water or fluids. 

"Second. — Milk containing less than 12 per centum of milk solids. 

"Tliird. — Milk containing less than 3 per centum of fats. 

"Fourth. — Milk drawn from animals within fifteen days before or five 
days after parturition. 

"Fifth. — Milk drawn from animals fed on distillery waste, or any sub- 
stance in a state of fermentation or putrefaction, or on any unhealthy food. 

"Sixth. — Milk drawn from cows kept in a crowded or unhealthy condi- 
tion. 

"Seventh. — Milk from which any part of the cream has been removed. 

"Eighth. — Milk which has been diluted with water or any other fluid, 
or to which has been added or into which has been introduced any foreign 
substance whatever. 

''Ninth. — Milk the temperature of which is higher than 50° F." 



Tuberculous Infection Through Milk. 

The question of tuberculous infection by ingestion of milk is answered 
in the negative by X. Aspe (Rev. d. Med. y Cir. Prac, Xov. 21, 1901). If 
the tubercle bacillus reaches the cow's udder, it must necessarily be carried 
thither by the blood. The bacillus has yet to be found in the blood; but, 
supposing its presence there, we are taught to believe that every gland in 
the body, by its selective power, takes from the blood only those elements 
which are necessary to the elaboration of its peculiar products. This would 
seem to dispose of the possibility of infection of the milk before it leaves 



106 INFANT FEEDING. 

the cow's body, unless the elective faculty, attributed to other glands, be 
denied to the mammary. Granting this possibility, if we recall that in the 
production of experimental infections by subcutaneous inoculation the first 
organs to be affected are the lymphatics, it is natural to suppose that the 
first and invariable effect of the ingestion of tuberculous milk would be the 
development of tabes mesenterica, yet primary tabes is comparatively rare. 
The author of this paper further raises the question of identity between the 
human and bovine tubercle bacillus, and quotes experiments in inoculation 
of cows with cultures from human tuberculous products with negative results 
in the nineteen animals experimented upon, whereas animals injected with 
the bovine form quickly succumbed, and autopsy showed tuberculous lesions. 

The Influence of High Temperature on Tubercle Bacilli in Milk. — 
Barthel and Stenstrom {Centr dibit, f. Bakt., October 8, 1901), in reviewing 
recorded experiments on the sterilization of tuberculous milk, remark on the 
very variable results obtained by different observers. Bang has stated that 
heating tuberculous milk to 80° C. is not sufficient to kill the bacilli, but 
that a temperature of 85° C. is sufficient for the purpose. Forster has found 
70° C. for five to ten minutes capable of killing the organisms; de Man, 70° 
C. for ten minutes, and 80° C. for five minutes. Galtier has shown that milk 
submitted to 70°, 75°, 80°, and 85° C. for six minutes is still capable of 
conveying infection, and others have had similar results. Barthel and Stens- 
trom have conducted experiments which go to show that the chemical reac- 
tion of the milk has much to do with the facility with which it is sterilized. 
The material was obtained from a cow with an udder in an advanced state of 
tuberculosis. Guinea-pigs were used to test the results, and the effect of 
65°, 70°, 75°, and 80° C. was studied. The results were positive in all 
cases; that is to say, a temperature of 80° C. for ten minutes, a temperature 
of 75° C. for fifteen minutes, 70° C. for fifteen minutes, and 65° C. for 
twenty minutes were all incapable of sterilizing the milk. These results 
the authors interpret as follows : Storch has shown that the chemical 
changes in milk are the more marked the more advanced the disease of the 
udder, and that the reaction becomes more and more markedly alkaline. 
On the other hand, it has long been known that it is more difficult to sterilize 
an alkaline than a neutral, and a neutral than an acid fluid. The specimen 
with which they worked was strongly alkaline, and to this they ascribe the 
difficulties in its sterilization. Variations in chemical reaction explain, in 
their opinion, the variations in the results obtained by other investigators. 

The Tuberculin Test of Pure-bred Cattle.— Mr. P. E. Salmon, D. V. M.. 
Chief of the Bureau of Animal Industry of the United States Department 
of Agriculture, has recently issued a pamphlet in which he demonstrates the 
necessity of guarding against the importation of disease by means of cattle, 
and upholds the present regulations to prevent such occurrences as proper 
and consistent, The chief danger to cattle arises from the prevalence of 



TUBERCULOUS [NFECTION THROUGH MILK. " K)7 

tuberculosis, which disease affects herds more widely and mere disastrously 
than any other. 

Even if the point urged by Professor Koch at the British Congress on 
Tuberculosis be granted, and it is allowed that the spread of tuberculosis by 
milk and meat is to be feared but to a slight extent, the fact must still be 
borne in mind that tuberculosis, in itself, is a decimating factor among 
cattle of immense importance. 

Mr. Salmon shows that the United States has a very large export trade 
in cattle, and one that is continually increasing. He further points out that 
rigid restrictions are in force in many countries in the world to prevent 
tuberculous beasts from gaining an entrance into those territories ; conse- 
quently, if we wish our cattle to enter those markets, they must not only be 
free from tuberculosis when they leave the farm, but also when they arrive 
in a foreign country. To effect this object, every effort must be put forth 
to keep out tuberculous cattle from this country, for a few thus diseased will 
quickly spread contagion. 

The argument is therefore advanced that the tuberculin test as now 
adopted must be strictly enforced to guard against such a result. The con- 
tention is likewise made that the pure-bred cattle mainly imported from 
Great Britain are the chief menace in this respect, and that, if the tuber- 
culin test were not strictly adhered to, the blue-blooded immigrants from 
the United Kingdom would disseminate the germs of tuberculosis among 
cattle from one end of the country to the other. 

Tubercle Bacilli Disseminated by Cows in Coughing, as a Possible 
Source of Contagion. — The general belief at the present time that the means 
by which tuberculosis is chiefly disseminated, by the inhalation of dried 
tuberculosis sputum which becomes pulverized and is carried about by cur- 
rents of air, or put into motion in other ways, has been strongly substan- 
tiated by numerous experiments. Fliigge, however, is not in accord with 
these views, and is of the opinion that the spread of tuberculosis is due 
mainly to the inhalation of minute particles of sputum which the act of 
coughing thus ejects. He further holds that these particles float in the 
air for a considerable period of time, and may be blown hither and thither 
by very slight currents. Klebs, in this country, has demonstrated the fact 
that, during the act of coughing, minute particles of sputum, often con- 
taining tubercle bacilli, are thrown out. At his instance, too, Curry, of 
Boston (Boston Medical and Surgical Journal, October, 1898, vol. cxxxix, 
Xo. 15), carried out a series of elaborate experiments with the object of 
thoroughly investigating the matter. 

Dr. Curry concluded from his experiments that, although there is a 
possible, and even a probable, danger from this source, Fliigge has greatly 
exaggerated this danger. Dr. Mazyck, lecturer and demonstrator of bac- 
teriology, A'eterinary Department, Uni versify of Pennsylvania, has been led 



108 INFANT FEEDING. 

to undertake experiments to see if it were not possible that cows in the act 
of coughing would likewise expel small particles of tuberculous material 
rich in tubercle bacilli. The results of these studies were made the subject 
of a paper by Dr. Mazyck, which was read before the Pathological Society 
of Philadelphia on November 8, 1900. The belief is common that cows 
when coughing swallow all their sputum, and do not project it to any extent. 
Dr. Mazyck, by ingenious methods devised by himself, has disproved this 
theory, and has practically demonstrated that, in the act of coughing, cows, 
as well as men, atomize, so to speak, their sputum, and project it into the air 
in minute particles, which may float for some time. Inoculation of guinea- 
pigs with this secretion gave a considerable proportion of positive results. 
Dr. Mazyck came to the conclusion that the danger of infection by means 
of this atomized sputum, as far as mankind goes, is confined practically to 
those in constant contact with the animals, but for other animals in the 
same stable the infected animals must be considered a source of danger. 
The moral to be derived from the outcome of Dr. Mazyck's experiments 
would seem to be that when tuberculosis is diagnosed in a cow she should 
be isolated as far as is possible ; at any rate, she should not be confined in 
a shed with healthy animals. 

Sterilization and Pasteurization vs. Tubercle-free Herds, etc. 1 — The 
comparative dependence upon sterilization or pasteurization and the insur- 
ance of absolute absence of tubercle in herds supplying milk are discussed 
by Hope, who thinks that, while raw milk is especially liable to contamina- 
tion, sterilization, valuable as it is, is, after all, only an expedient, and must 
not be put in such prominence that the importance of the other safeguards 
of absolute cleanliness of source and handling are neglected. Beyond any 
question, he says, the ultimate advantage lies in obtaining the milk from 
herds free from tuberculosis. A comparison is made with having water 
from a contaminated source and making it pure later by chemical processes 
or boiling it, and obtaining it in the first place from an uncontaminated 
source. He thinks it is quite possible to insure that the milk supply shall 
come from cows free from tuberculosis. 

The State Veterinarian of Pennsylvania, Dr. Pearson, thinks that not 
over 2 per cent, of the cattle of that State are tuberculous, and probably 
if a general test of all the cattle of the other States mentioned were made 
we should find a very much smaller proportion tuberculous than is indicated 
by this tabular statement. The explanation of the high percentages that 
have been given is found in the fact that it has been, for the most part, 
suspected herds which have been tested. Admitting that the greater part 
of these percentages are too high, we still have revealed a condition which 
is worthy of our serious consideration. 



E. W. Hope (The Lancet), 



TUBERCULOUS INFECTION THROUGH MILK. 



109 



The classes of animals mosl affected are breeding animals and dairy 
stock. The beef cattle coming to our markets are still singularly free from 
tuberculosis. Of 1,841,166 cattle slaughtered in the year 1900 under Fed- 
eral inspection, but 5279, or 0.11 per cent., were sufficiently affected to cause 
the condemnation of any part of the carcass. Of 23,336,884 hogs similarly 
inspected, 5440 were sufficiently affected to cause condemnation of some part 
of the carcass. This is equal to 0.023 per cent., or slightly more than one- 
fifth the proportion found in beef cattle. It is scarcely necessary to add that 
there are certain lots of cattle and hogs encountered which are affected in 
much greater proportion than the general average just given. 

From a recent view by Drs. Russell and Hastings, of the Wisconsin 
Agricultural Experiment Station, 1 of the tests of cattle for tuberculosis 
made in the United States, the following summary is presented: — 

Table No. 20. 



Vermont . 

Massachusetts 

Massachusetts, entire herds 

Connecticut 

New York, 1894 . 

New York, 1897-98 

Pennsylvania 

New Jersey 

Illinois, 1897-98 

Illinois, 1899 . 

Michigan 

Minnesota 

Iowa 

Wisconsin — 
Experiment Station tests : 

Suspected herds ... 

Non-suspected herds . 

State Veterinarian's tests : 

Suspected herds 

Tests of local veterinarians under State 
Veterinarian on cattle intended for 
shipment to States requiring tuber- 
culin certificate 



Number 
Tested. 



60,000 
24,685 

4,093 

6,300 
947 

1,200 

34,000 

22,500 

929 

3,655 

3,430 
873 



323 
935 

588 



3,421 



Number 
Tuberculosis. 



2,390 

12,443 

1,080 

' 66 

163 

4,800 



560 



122 



115 

84 

191 



76 



Per cent. 
Tuberculosis. 



3.9 
50.0 
26.4 
14.2 

6.9 
18.4 
14.1 
21.4 
12.0 
15.32 
13.0 
11.1 
13.8 



35.6 
9.0 

32.5 



2.2 



The following suggestions, adapted from the fifty dairy rules of the 
United States Department of Agriculture, are recommended for strict adop- 
tion in our dairies : — 

The Stable. — Keep dairy cattle in a room or building by themselves. 
It is preferable, when possible, to have no cellar below and no storage loft 
above. The stables should be well ventilated, lighted, and drained; should 
have tight floors and walls and plainly constructed. Store the manure under 
cover outside the cow stable, and remove it to a distance as often as prac- 



1 Bulletin No. 84, Wisconsin Agricultural Experiment Station, March, 1901, 



HO IXFAXT FEEDING. 

ticable. Whitewash the stables once or twice a rear; use land plaster in 
the manure gutters daily. Clean and thoroughly air the stable before milk- 
ing; in hot weather sprinkle the floor. 

The Cows. — Have the herd examined at least twice a year by a skilled 
veterinarian. Promptly remove from the herd any animal suspected of 
being in bad health and reject her milk. Xever add an animal to the herd 
until certain it is free from disease, especially tuberculosis. Do not allow 
the cows to be excited by hard driving, abuse, loud talking, or any unneces- 
sary disturbance. Feed liberally, and use only fresh, palatable food stuffs. 
Provide water in abundance, easy of access, and always pure. Do not allow 
any strongly flavored food, like garlic, cabbage, turnips, to be eaten except 
immediately after milking. Clean the entire body of the cow daily. If the 
hair in the region of the udder is not easily kept clean, it should be clipped. 
If the sides of the cow are plastered with dirt or manure, as is often the 
ease, a certain amount is sure to fall into the pail of milk. This is where 
the trouble really begins, for this dirt and manure abound in bacteria which 
cause decomposition in milk, and thereby induce bowel disturbances. 

The Milk. — The milker should be clean in all respects. He should wash 
and dry his hands and clean his nails just before milking. After the hands 
have been washed, a little vaseline may be used on them, thereby preventing 
scales from the teat or fingers getting into the milk. The milker should 
wear clean, dry garments, used only when milking, and kept in a clean place 
at other times. Brush the udder and surrounding parts just before milking, 
and wipe them with a clean, damp cloth or sponge. Commence milking at 
the same hour every morning and evening, and milk quietly and thoroughly. 
Throw away (but not on the floor — better in the gutter) the first few streams 
from each teat. This first milk is watery and of little value, and during 
the intervals between milking, the bacteria from the air get into the cow's 
teats and grow with great rapidity. These bacteria cause early souring of the 
milk. If in any milking a part of the milk is bloody or stringy or un- 
natural in appearance, the whole mass should be rejected. Milk with dry 
hands, or oiled as above ; never allow the hands to come in contact with the 
milk. If any accident occurs by which the pail, full or partly full, of milk 
becomes dirty, do not try to remove this by straining, but reject all this 
milk and rinse the pail. 

Care of the Milk. — Eemove the milk of every cow from the dairy at 
once to a clean, dry room, where the air is pure and sweet. Do not allow 
cans to remain in. stables while they are being filled. Strain the milk through 
a metal gauze and a flannel cloth, or layer of cotton, as soon as it is drawn. 
Aerate and cool the milk as soon as strained. The rapid aeration and cooling 
of milk are matters of great importance. Combined aerators and coolers, 
suitable for use with well water or ice water, can be had at any dairy supply 
house at a small cost. By using one of these, the cow odor, the animal heat, 



RAW MILK. 11 1 

and much of the dirt ran be removed from milk in a few minutes. The milk 
should be cooled to 15° F., if for shipment, or to 60° F., if for home use or 

delivery to a factory. Never mix fresh, warm milk with that which has 
been cooled. Do nol allow the milk to freeze. When cans are hauled a dis- 
tance they should be full and carried in a spring wagon. In hot weather 
cover the cans, when moved in a wagon, with a clean, wet blanket or canvas. 
If milk is stored, it should be held in tanks of fresh, cold water, renewed 
daily, in a clean, cold, dry room. Clean all dairy utensils by first thoroughly 
rinsing them in warm water; then clean inside and out with a brush and 
hot water into which a cleansing material is dissolved; then rinse, and lastly 
sterilize by boiling water or steam. Fse pure water only. After cleaning, 
keep the utensils inverted in pure air and sun if possible, until wanted for 
use. Old cans, in which parts of the tin are worn off, or where there are 
seams and cracks, are impossible to keep clean, and should not be employed. 

Small Animals. — Cats and dogs must not be in the stables during the 
time of milking. The reason for this is that cats are peculiarly liable to 
transmit diphtheria; both cats and dogs have disgusting skin diseases which 
may be transmitted to children, and both animals also are apt to nose 
around and dirty the utensils. 

If precautions like the above are strictly carried out, the milk will be 
clean and remain fresh for a considerable length of time. The fresher the 
milk is, the better it will be for family use. The test for uncleanliness con- 
sists in an increase in the proportion of lactic acid generated in the mill-, 
and in a large increase in the number of bacteria per cubic centimeter. 

The Xew York Senate passed a bill recently, forbidding sale of milk 
containing formaldehyde or salicylic acid, owing to their injurious effects on 
infants. 

Eaw Milk. 

Monrad (Jahrbnch f. Kinderheil~kunde, Xo. 55, p. 61) describes a 
series of children fed with raw milk. These infants could not digest ster- 
ilized or boiled milk. Their condition improved when raw milk was sub- 
stituted. It was interesting to note that during the course of Monrad's 
investigations an infant received sterilized milk by mistake, and its former 
dyspeptic symptoms reappeared. 

Jensen found that new-born calves assimilated raw milk, but when 
boile^ v*ilk was given, they were subject to coli-enteritis. Such calves that 
recovered were atrophic. Milk, when subjected to prolonged sterilization, 
such as tyndalizing the milk, undergoes certain chemical changes. These 
are: — 

1. Xuelein and lecithin are rendered insoluble. 

2. Milk-sugar is completely changed. 

3. The coagulability of the casein is impaired. 

4. The fat globules are separated and rise to the surface of the milk. 






112 



INFANT FEEDING. 






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HAW MILK 



L13 



5. By the influence of the chlorides on the casein peptones arc formed 
in the milk. 

6, The milk is rendered unpalatable by this superheating. 

:. The albumin is rendered much less assimilable by prolonged heating. 
The increased number of cases of rickets and Barlow's disease since the 
advent of sterilization docs not speak well for this process. 
Certain factors should he noted: — 

1. That sterilization is intended to kill pathogenic bacteria in the 
milk. 

2. That not only are pathogenic bacteria destroyed, but also sapro- 
phytes, which certainly have some hearing on the digestive functions of an 
infant, 

"We know that the proteolytic bacteria are in the milk for certain 
reasons : — 

1. To coagulate the casein. 

2. To peptonize this coagulated casein. 

It is possible that by sterilizing milk and destroying these bacteria, we 
rob the milk of microbes necessary to perform certain aids in the digestive 
process. 

Such assistance in the digestion of milk may not be necessary in the 
robust and normal infant, but it is quite different when we are dealing with 
dyspeptic or atrophic infants. 

When infants thrive on sterilized milk, then it is a good plan to con- 
tinue the same; but if dyspeptic symptoms — vomiting and undigested, cheesy 
stools with colicky symptoms — show themselves, then such food should be 
discontinued. Such cases demand a radical change of diet, and it is here 
that an easily assimilated form of food is indicated. Such food is raw milk. 

Scorbutic cases in which we continue giving sterilized milk will not be 
modified whether we add HC1, pepsin, or alkalies. The character of the 
food is at fault and a radical change must be made. For the treatment of 
atrophy nothing will supersede raw milk. Certain precautions must be taken 
in securing raw milk for infant feeding. 

The ideal cows' milk is clean, raw milk. By this is meant milk free 
from all possible contamination. Such milk should be obtained from a 
stable having all modern hygienic surroundings. If greater attention were 
bestowed on the condition of the cow, the cow's udder, the stable, the 
bucket, the hands of the milker, then less sterilization and pasteurization 
would be necessary. Let it be distinctly understood that certain chemical 
changes are brought about in milk when it is steamed, be it in the 
process of sterilization or pasteurization. Neither sterilization nor pasteur- 
ization add* to the digestibility of mill-. Indeed, chemical experience has 
demonstrated the fact that raw milk, sold in some places as certified milk, 
in the Walker-Gordon milk laboratories as guaranteed milk, is more easily 



114 INFANT FEEDING. 

assimilated. It is proven by the condition of the stools as well as the gas- 
tric digestion. 

Xature lias given ns a good example of how milk should be fed to an 
infant. Breast-milk is certainly raw mill-, and is served to the infant at 
the temperature of the body. Xot only does boiling and steaming of milk 
produce chemical changes in the albuminoids, but it renders the process of 
digestion much more difficult, and thus it is that most infants taking boiled 
milk surfer with constipation. This is not so, however, in the case of infants 
fed on raw milk. 

When sterilized and pasteurized milks are found to disagree with chil- 
dren, raw milk may sometimes be easily assimilated. Thus it will be found 
that, while boiled milk, or sterilized or pasteurized milk, given either whole 
or with its proper dilution to suit the various ages, will provoke constipa- 
tion, by substituting raw milk for heated milk the same will be more easily 
assimilated. The author has frequently noted decided antiscorbutic prop- 
erties in fresh raw milk. In children with pronounced rickets, and even 
scurvy, the withdrawal of sterilized or other milk and the substituting of 
fresh raw milk will work surprising changes. 

Biedert 1 states that he has followed Escherich and Epstein, who rec- 
ommend giving full milk to children at birth. In Erance, Budin and H. 
de Bothschild, and more recently E. Schlesinger, in Germany, have given 
undiluted milk to both sick and well children as a substitute for breast- 
milk. Biedert claims to have seen good results in some instances, but 
cannot recommend whole milk, as a rule, for feeding children. Marfan, 
another advocate of pure-milk feeding, believes that milk should be diluted 
until the fourth or fifth month, but later he advises pure-milk feeding. 
Schlesinger, of Breslau, while giving pure milk, gives a longer interval 
between the meals. That the greatest possible success is not achieved 
by this method in France can be judged by the statement of Marfan 
while discussing the subject of athrepsia. He says: te Wa jamais vn 
Vathrepsie confirmee se terminer favorablement." Thus it seems that even 
we have much better results than the French, for there are certainly a great 
many children who can and will digest a diluted milk, and thin milk-and- 
cream mixtures, as shown by their stool, their sleep, and their increase in 
weight. These same children with enfeebled digestive functions will in- 
variably show gastric disturbances — such as vomiting, colic, constipation, or 
diarrhoea, restlessness, sleeplessness — and will cry continually when given 
whole milk. So that whole-milk feeding is not assimilated during the early 
months of a child's life ; besides they do not increase in weight. This 
method of feeding has been tried over and over again, and we are compelled 
to discontinue the heavier food, consisting of whole milk, and substitute a 
light food, consisting of diluted milk. 

1 Fourth Edition of Kinderernahrung, 1900, page 184. 



HAW MILK. 



115 



Fresh Raw Milk. — Just as the medical profession, and to sonic extent 
the laity, have become impressed with the idea thai milk should be boiled 

before being used, to insure the destruction of the microbes which it contains. 

> 

Dr. Freudenrich comes forward with a series o\' experiments, by which 
he claims to prove that raw milk possesses remarkahle germicidal proper- 
ties. According to his experiments, the bacillus of cholera, when put 
into fresh cows' milk, dies in one hour, the bacillus of typhoid fever suc- 
cumbs at the end of twenty-four hours, while other germs die at the end 
of varying periods. 

Milk which has been exposed to a temperature of 131° F. loses its 
germicidal properties. Milk which is four or five days old is also devoid of 
microbe-killing power. 1 

Undiluted Milk as a Food for Infants. — Xotwithstanding tireless re- 
search and wonderful ingenuity, a perfect substitute to replace mother's 
milk as an article of food for the nourishment of infants yet remains to be 
discovered. This is greatly to be regretted, as the occasions are not rare on 
which mother's milk is not available, or it is desirable or even necessary 
to have recourse to such a substitute. The fact is that there is yet not a 
little to learn concerning the assimilative processes in children, and knowl- 
edge, particularly of a practical character, concerning food is not so exten- 
sive or so precise as it might be. As K. Oppenheimer points out in a recent 
communication, an article of food for the infant to serve as a perfect sub- 
stitute for mother's milk should be as useful as the latter in the nourish- 
ment both of healthy children and of those suffering from gastro-intestinal 
catarrh. These requirements, however, are not met by any of the large 
number of artificial foods that have been devised. For the purpose of estab- 
lishing the usefulness of undiluted cows' milk as judged by this standard, 
Oppenheimer made comparative observations in normal healthy children, 
in infants suffering from gastro-intestinal derangement, and in atrophic 
children. In almost all of the 11 cases of the first group the body weight 
exhibited a steady and uniform increase, while of 36 cases of the second 
group only 6 failed to do well, and of 12 cases exhibiting marked atrophy 
8 failed to do well. All of the foregoing cases were under observation for 
periods of more than four weeks. Of 33 additional cases under observation 
for a shorter period than four weeks, 20 thrived and 13 did not. 

The Dangers. — We naturally regard the dangers of having tubercle 
bacilli in the milk as one of the prime reasons for sterilizing the same. We 
should never employ the milk from one cow, hut always from a mixed herd. 

The danger of transmitting tuberculosis is certainly very rare. Au- 
thentic cases have been reported from time to time in medical literature 



'Bacteriological World. December, 1891; Journal of the American Medical 
Association, Februarv 27. 1892. 



HO INFANT FEEDIXG. 

in which a supposed infection could be attributed to milk. R. Koch disputes 
the possibility of transmitting bovine tuberculosis to man. 

In a herd of cows which has undergone the proper veterinary inspection, 
the danger of overseeing tuberculosis of the udder is reduced to a minimum. 

Chemical Examination of Cows' Milk. 
Fat. 1 

The fat required for an infant fed on cows' milk is about 1 per cent, 
on the second day after birth. If the child is normal we can usually give it 
2 per cent, at the end of the first Aveek ; 2 per cent, of fat is usually sufficient 
for the first month. Some infants can do well with a feeding mixture 
containing this amount of fat for the first two months, while other infants 
of the same age, but with better digestive functions, can assimilate 3 per 
cent, of fat at the end of the first month. During the second month infants 
usually digest 2y 2 per cent, of fat. At three months we can -order 3 per 
cent, if normal conditions exist. 

The dangers of excessive fat feeding have been pointed out by 
Czerny, Meyer, and many others. In America the profession has been 
educated to regard top milk feeding and high fats as the ideal method of 
nutrition for young and older infants. When intestinal disturbances exist, 
we must inquire concerning the carbohydrates, because frequently it is the 
milk sugar causing irritation due to decomposition, and excess of fat may 
be suspected. 

It is impossible to form definite data concerning the quantity of fat 
by expressing a few drops of milk from the human breast. For example: 
while the fat content in an early specimen of milk by expression and 
before the nursing act commences was 0.94, the fat per cent, gradually rose 
until a later specimen showed as much as 6.6 per cent, and the whole mixed 
specimen of early and late milk yielded a fat content of 3.77 per cent. 
Variations, therefore, should be remembered when estimating the fat per 
cent, of a given quantity of milk. 

Fat Metabolism. — It seems to be established that the mucous membrane 
of the stomach secretes an enzyme or fat-splitting ferment. Ibrahim dis- 
covered a lipolytic ferment in the stomach of a nursling. 

The digestion of fat begins in the stomach and is continued in the 
intestine. This synthesis of the fatty acids in the fat is a function of the 
intestinal epithelium associated with the secretion of the pancreas and 
other intestinal glands. Regarding the absorption of fat, we must not 
suppose that all fat found in the faeces is un absorbed fat from the food. 
Normally the stool contains from 1 to 10 per cent, of fat, besides free fatty 
acids and their combinations with saponified fats. Fat is not the most 



1 Read also chapter on "Cream. 






FAT. 



11 



important item of nutrition, because fat may be replaced by a certain 
quantity of carbohydrate. Whether an infant could live entirely without 
fat and receive in its stead a given quantity of carbohydrate has never been 
proven. Theoretically it is possible. 

Babcock's Milk Test. — In this country the so-called Babcock milk test, 
invented by Dr. S. M. Babcock, has been adopted in preference to other 
practical milk tests, in creameries and cheese factories as we'd as in milk 
laboratories. The cause of the general adoption of this test is doubtless 
to be found in its simplicity, cheapness, and ease of manipulation. Briefly 
stated, the test is operated as follows: 17.6 cubic centimeters of milk are 
measured into a special milk-test bottle, an equal quantity of commercial 
H 2 S0 4 (specific gravity, about 1.83) is added, and after mixing the two 
liquids the test bottle is placed in a centrifugal machine and whirled for 
four minutes; hot water is then added to the bottle to bring the fat into 




Fig. 37. — Centrifugal Testing Machine, for Handpower. 

graduated narrow neck of the bottle, and after a second whirling of one 
minute the per cent, of fat in the milk is read off from the scale of the 
test bottle. 

A determination of fat in milk by this method takes less than fifteen 
minutes, and when care is taken in sampling the milk and reading of the 
result is accurate to within one-tenth of 1 per cent. Babcock testers are. 
now placed on the market by many manufacturers of dairy supplies and at 
a remarkably low price, thanks to sharp competition among the manufac- 
turers. The testers are either hand or power "(steam or motor) machines 
and built to hold from two to thirty or more test bottles at a time. The 
number of revolutions at which they must be run ranges from 800 to 1200 
per minute, according to the diameter of the testers. 

The Determination of Fat. — The simplest method is by the cream gauge 
(Fig. 38). Although its results are only approximate, they are in most 
eases sufficiently accurate for c'inical purposes. The tube is filled to the 
zero mark with freshly drawn milk, which stands at a room temperature for 
twenty-four hours, when the percentage of cream is read off. The ratio of 
cream to fat is approximately 5 to 3 ; thus, 5 per cent, cream represents 3 
per cent, fat, etc. 

Another rapid method is by Marchand's tube. 



118 



INFANT FEEDING. 



Marchand's Test. — First put into the tube live cubic centimeters of 
milk, up to the line M; then four or live drops of liquor sodse; shake; add 
five cubic centimeters of ether, up to the line E. Cork, and shake fifteen 
or twenty times; add 90 per cent, alcohol, up to the line A. The tube is 
now tightly corked, shaken thoroughly, and placed upright in a tall bottle 




n 



f t r i 



Fig. 38.— Graduated Cream 
Gauge, 10X1>2. 



CMj 



Pig. 39.— Marchand's Tube. 



Fig. 40.— Feser's Lactoscope. 



containing water at a temperature of 120° to 150° F. The fat separates 
and forms a distinct layer at the top, and after half an hour the amount is 
read off in degrees. By reference to the following table the exact percentage 
of fat is shown : — 

Table No. 22. 



Degrees, Marchand. 


Percentage of Fat. 


Degrees, Marchand. 


Percentage of Fat. 


1 


1.49 


13 


4.29 


3 


1.96 


15 


4.75 


5 


2.42 


17 


522 


7 


2.89 


19 


5.68 


9 


3.36 


21 


6.14 


11 


3.82 







Each additional degree oil the tube corresponds to 0.23 per cent, of fat. 
To insure accuracy the test should be repeated two or three times with the 
same specimen. 1 

Another test is made by the use of Feser's lactoscope. (See Fig. 40.) 
The test is made as follows : Four cubic centimeters of milk are measured 



These tubes may be obtained from E. Greiner, 51 William Street, New York. 



SUGAB 



L19 



off in a pipet, put into a tube, and water slowly added, shaking from time to 
time until the black lines of the porcelain stem at A are clearly visible 
through the mixture of milk and water. The 1 percentage of fat is then read 
off on the glass cylinder at the level of the water added; thus, if the water 
is to the mark I, it indicates the presence of 4 per cent, of fat. This test 
is only applicable to cows' milk. 

It seems to be pretty well settled that the fat in woman's milk usually 
varies between 3 and 5 per cent., the sugar between 4 and 8 per cent., 




Fig. 41. — Cows' Milk, Showing Fat-globules, Magnified 330 Diameters. 

proteids (albumin and casein) between 1 and 2 per cent., and the ash 
between 0.2 and 0.4 per cent., the water being about 88 per cent. Wide 
extremes are met with; so it is useless to think of woman's milk as of a 
certain composition. 

Sugar. 

Milk Sugar (Lactose). — Milk sugar has a laxative tendency most 
probably due to its slow absorption. It also has a tendency to irritate the 
intestinal epithelium. Its transformation into lactic acid causes fermenta- 
tion. A theoretical reason for increase in bodily weight when feeding 
sugar, is that such sugar requires a certain amount of water to hold it in 



120 



IXFAXT FEEDING. 



suspension. Large quantities of sugar have a decided influence on the 
temperature of the body. A rise in temperature will follow when a large 
dose of glucose is given, and a- higher fever curve will be noted when a dose 
of 15 to 30 grams of lactose has been given. 

In infantile feeding, dextrine and maltose sugars produce less diar- 
rhoea and fever than the pure sugars. The condition of the intestinal tract, 
especially when whey feeding is given, permits fever to result when sugar 
in doses of 10 to 30 grams once only is given. 

Milk sugar causes abnormal acid fermentation ; this results in symptoms 
of intestinal irritation due to destruction of epithelium, which interferes 
with the proper emulsification of fats ; therefore, the presence of fats acts as 
an additional irritant and provokes loose bowels. 

When intestinal irritation exists caused by the presence of milk sugar 
the symptoms will continue even though the milk sugar has been greatly 
reduced, because even small quantities of this milk sugar will keep up 
lactic acid fermentation and consequent destruction of the epithelium. 

Each sugar has its specific ferment in the intestine : Lactose has 
lactase, maltose has maltase, and cane sugar has invertin. These sugars are 
all acted upon in the mouth by the ptyalin of the saliva. They are further 
acted upon by the diastasic ferment of the intestine and the pancreatic juice 
which transforms the polysaccharide into monosaccharide. 

Sugar is never found under normal conditions in faeces, although 
abnormal quantities of sugar, when given by mouth, may be found in the 
urine. 

Cane Sugar (Sucrose). — Modern research has proven that cane sugar 
is adapted for infant feeding. When prescribing cane sugar, one-half the 
quantity of ordinary milk sugar is ordered. Cane sugar is employed in 
commerce to preserve milk foods, which proves that this form of sugar 
possesses antibactericidal properties. 

My own experience with cane sugar is excellent. When prescribing 
sugar for home modification it is well to order 2 per cent, cane-sugar 
solution. The weight of the infant is the criterion as to whether or not the 
sugar element (carbohydrate) should be increased. If the weight is sta- 
tionary increase the sugar % P er cent, daily until 5 per cent, is given. 

Table No. 23. 



Comparative Average. 


Woman's Milk. 
Per Cent. 


Cows' Milk. 
Per Cent 


Fat 


4.00 
1.50 
7.00 
0.20 
87.30 


3.50 


Proteids 


4.00 


Sugar 

Salts 


4.30 
0.70 


Water 


87.50 








100.00 


100.00 



A Mil MINOIDS IN COWS' MILK. 



121 



The nutrient value of sugar is certainly overestimated. We know, 
according to chemists, that carnivorous animals do not secrete sugar to any 
appreciable extent. That sugar is not a necessary element of food can be 
seen by the fact that canines secrete no sugar in their milk, and still a small 
slut can nurse seven or eight puppies and keep them all fat. Condensed 
milk is certainly made up chiefly of sugar. "We all know that infants reared 
on this food have rickets more readily and succumb to gastro-intestinal and 
infectious disorders more easily than infants on any other form of feeding. 

When milk sugar is converted into glucose and galactose, we physio- 
logically have a gradual conversion into lactic acid, which may aid in the 
digestion of the proteids, thus giving us a very valuable addition to the 
means at our command for rendering modified cows' milk digestible 
(Poteh). 

Sugar is too Low. — If the sugar is too low the gain in weight is apt 
to be slower than when furnished in proper amount. 

Sugar in Excess. — Symptoms indicating an excess of sugar: Colic or 
thin, green, very acid stools, sometimes causing irritation of the buttocks; 
sometimes there is regurgitation of food and eructations of gas. 



Albuminoids ix Cows' Milk. . 

That there are differences in the amounts of the albuminoids occurring 
in human milk is proven by the fact that, while Professor Leeds found a 
variation of 0.85 to -±.86, Professor Meiggs asserts that there was but 1 per 
cent. 

Konig, an earlier analyst, makes the variation from 0.85 to 4.86. Some 
of these results give as high a percentage of albuminoids in woman's milk 
as we find in cows' milk, and I have no doubt in my own mind that the time 
and habit of extracting the milk has a deal to do with the amount of occur- 
ring albuminoids. In other words, when milk is extracted every two hours 
or less, it cannot contain as much of the cell-material as milk from the same 
source extracted at intervals of twelve hours. This latter is riper, and it is 
the non-conformity of the tissue which causes all the difference in the dif- 
ferent occurring albuminoids. We know that during the incubation of eggs 
casein is developed from egg-albumin. This illustrates the ripening of albu- 
min. Furthermore, take an egg just laid by the hen, and boil it. and you 
will find immature albumin in it, that is, after boiling, instead of being 
thick and firm, like an older egg, much of it is milky. If boiled a few hours 
later, all the albumin will coagulate perfectly, because it has had time to 
ripen. There is no doubt that the albuminoids in milk from healthy animals 
are all cell-transformations, not an exudate, as are undoubtedly the fats and 
salts, because these latter we can influence by the food very plainly, but in 
health the albuminoids are constant without regard to food, while during 



122 IXFANT FEEDING. 

menstruation, pregnancy, and other conditions, notably febrile disturbances, 
we find the fats and salts not materially affected, but the albuminoids de- 
creased, increased, or totally changed, as in the case of colostrum. The 
casein, besides being riper in cows' mill-, by reason of its stronger growth, 
is intended by Xature to coagulate into a hard mass, because it is the product 
of a cud-chewer for the nourishment of a cud-chewer, and the reason why 
it does not always coagulate in the infant's stomach as it does in that of 
the calf is that the latter animal's stomach secretes a principle called clnj- 
mosinj this is the principle that curdles cows' milk, and it operates either 
in an acid or an alkaline medium. Pepsin will not coagulate milk, and 
hence the hard coagulum of cows' milk that sometimes forms in the infant's 
stomach is due to acidity of that organ, and this acidity is not always the 
fault of the stomach, but of the milk itself. The variations in the chemistry 
of the albuminoids found in cows' milk would not be surprising to anyone 
if he would examine into the condition of some of its mammary sources. 
Thus it will often be found, en dissecting a cow's udder, that there are old 
cicatrices, one or more quarters of the udder intensely inflamed, sometimes 
a mammiferous duct clogged with a calculus or a clot of fibrin. Besides 
these pathological conditions, the mammary gland is subject to benign and 
malign infiltrations, bacillary tubercular deposits, and eruptive diseases of 
the skin involving the gland and ducts. Therefore, that fibrin, serum, and 
albumin, in various forms, are found in the cow's milk is not surprising, and 
it can safely be assumed that any variation in the albuminoids from the 
normal casein can be ascribed to sickness on the part of the animal. 

The Proteids. 1 

The proteids are one of the most, if not the most, important constit- 
uents of milk. Deficiency of proteids means retarded development. The 
proteids have always been regarded as the backbone of food. They have a 
group of closely related substances which are perhaps modifications of the 
same body. The proteids are the albuminous compounds. 

According to Paw, the nitrogenous compounds are mainly "histoge- 
netic" or tissue-forming material. By the separation of urea which occurs 
in this metamorphosis in the animal system, a hydrocarbonaceous compound 
is left which may be appropriated to heat production. 

When we examine the proteids of human milk, we find that the anal- 
ysis shows : — 

Table Xo. 24. 

Human Milk. Cows' Milk. 

C'aseinogen . . .Small Amount C'aseinogen . . .Large Amount 

Laetalbumin .Large Amount Lactalbumin .Small Amount 



1 See also article Laboratory Modification, page 173. 



THE PROTEIDS. [23 

In human milk Konig finds the lactalbumin is about two-thirds (%) 
and the caseinogen about one-third (%) of the total proteids. In cows' 

milk- the lactalbumin is only one-sixth (%) to five-sixths (%) caseinogen. 

L'oteh, reasoning from this standpoint, advises, in writing a prescrip- 
tion which calls lor a total proteid of 1 per cent., that we should calculate 
to have <>.i-"> per cent, lactalbumin and 0.25 per cent, caseinogen. 

A prescription calling for fat, 3 per cent.; sugar, 6 per cent.; proteid, 
1 per cent.; alkalinity. 5 per cent,, would be written as follows: — 

Per Cent. 

ft Fat 3.00 

Sugar tf.00 

Proteids (total ) 1.00 

(a ) Lactalbumin 0.75 

( b ) Caseinogen 0.25 

Number of feedings 9 

Amount at each feeding 75 c.c. (5*2%) 

Infant's age . . . , 3 weeks 

Infant's weight 9 pounds 

Alkalinity 5 per cent. 

Heat at 155° F. 

It is to be noted that, although the total proteid percentage in the milk 
for an infant may he considerably increased, it is these higher percentages 
which are the most irrational in their nutritive values in the eaidy months 
of infancy, if we hold to the rule that the caseinogen should be only one- 
third of the total proteids. This ratio of lactalbumin to caseinogen can be 
obtained if we are writing for a low proteid, as in the above prescription, or 
in a prescription calling for a total ' proteid percentage of 0.75, of which 
0.25 per cent, shall be caseinogen and 0.50 per cent, lactalbumin. If, on 
the other hand, we write for a high total proteid, such as 3 per cent., the 
highest percentage of lactalbumin that can be obtained is 0.85, and the 
remaining 2.15 per cent, is caseinogen, which practically reverses our ratio. 

It can be said, however, that as the infant grows older its power to 
digest casein becomes proportionately greater, so that in the later months 
of infancy, the tenth, eleventh, and twelfth, its proteolytic function has 
become adapted to this change in the ratio of the caseinogen and lactalbumin, 
so that the higher total proteids, such as 2.50, 3, 3.50, and finally 4 per 
cent., with the relatively high caseinogen and low lactalbumin, become the 
proper nutritive portion for the infant. 

The point especially to be emphasized is that in the early months of 
life, which demand a low proteid percentage, we can by the use of whey 
obtain, in a modified milk, the same proportions of lactalbumin and case- 
inogen which we find in human breast-milk at a corresponding period of 
infancv. 



124 INFANT FEEDING. 



Casein. 

According to Finkelstein and Meyer, casein can be fed to very sick 
infants and will be assimilated in small or in large doses. Casein stimulates 
alkaline secretion ; hence, acts antagonistic to pathological acid fermentation. 
Casein is, therefore, indicated to combat diarrhoea. This teaching, based on 
experimental feeding, reverses our former theories concerning the dangers 
of giving large percentages of proteid. This form of food, recommended by 
Finkelstein, of Berlin, has gained a strong foothold in many clinics abroad. 
It has been successfully used by me in cases of intestinal disturbance, 
enteritis (dyspepsia), atrophy (decomposition), and cholera infantum 
(intoxication). Fever, if present, does not contraindicate the use of this 
food. It has a low sugar and a low salt content. 

Casein Milk. — Finkelstein's method of preparing the milk is as fol- 
lows 1 : Heat 1 quart of full milk to 100° F. Add 4 teaspoonfuls of the 
e:sence of pepsin and stir. Let this mixture stand at 100° F. until the 
curd has formed (this usually takes about one-half hour). Filter off the 
whey from the curd by means of a linen cloth, and hang up the cloth con- 
taining the curd for one-half hour in order to be rid of the whey. The 
curd is then removed from the cloth and pressed through a rather fine sieve 
two or three times by means of a wooden mallet or spoon. One pint of 
water is added to the curd during this process. The mixture should now 
look like milk, and the precipitate must be very finely divided. To this 
mixture 1 pint of buttermilk is added. 

The composition of this "casein milk" is as follows : — 

Proteid 3.0 per cent. 

Fats 2.5 per cent. 

Sugar 1.5 per cent. 

Salts 0.5 per cent. 

Casein milk should be given in small quantities in enteritis, and in 
large amounts in atrophy, every two, three, or four hours, depending on 
the age of the infant. Sugar should not be increased until the stools are 
homogeneous. Until sugar is added the weight does not increase. Cane 
sugar should always be used. This method of feeding should be continued 
for months, but should always be used as a corrective for the gastro- 
intestinal disturbance. It should be used as a substitute feeding if artificial 
feeding disagrees or deranges the gastro-intestinal tract. 

A Clinical Method for the Estimation of Breast-milk Proteids. 2 — "Two 
'milk-burettes,' each containing 5 cubic centimeters of milk, are subjected to 



1 Archives of Pediatrics, August, 1910. 

2 Reprinted in large part from George Woodward's article in the Phila. Med. 
Journal, May 21, 1898. 



CASEIN. 



125 



a temperature warm enough to rapidly sour the milk, and are allowed to 
remain in this warmth until a distinct precipitation can be seen. The 

burettes are then cooled in water, the milk-serum is withdrawn into the 
graduated tubes, 10 cubic centimeters of Esbach's solution (picric acid, 5 
grams; citric acid, 10 grams; water, 500 cubic centimeters) are added, the 
tubes are shaken and centrifugated, and the resulting precipitate is read. 
This reading expresses in percentage the total amount of proteids in the milk. 

"Such is a bare statement of the method. I will briefly take up the 
various steps in detail. The 'milk-burettes' are made of about 10 cubic 
centimeters' capacity, and have a glass pinch- 
cock or valve and a narrow exit-tube about 
an inch long (Fig. 42). 

"I have tried various forms of burettes 
and separating funnels, and find this the 
most satisfactory. A temperature of from 
95° to 100° F. is the most rapidly effective 
to produce fermentation. This I have most 
conveniently obtained by placing the tubes 
in a burette-stand, and the stand in contact 
with a radiator. The time required to 
obtain a distinct precipitation of casein is 
from eighteen to twenty-four hours. At the 
end of this time the milk lias distinctly 
separated into an upper layer of viscid 
yellow fat; a lower layer of fluid milk, quite 
opaque above, almost translucent below, and 
clinging to the sides of the tube, and espe- 
cially at the bottom, a granular precipitate. 
The cooling of the milk increases the viscid- 
ity of the fat and facilitates its separation 
from the milk-serum. The milk-serum is 

received into 15-cubic-centimeter graduated tubes, the solution of picric acid 
and citric acid added up to the 15-cubic-centimeter mark, the mixture 
stirred with a glass rod and placed in the hand-centrifuge. The amount of 
centrif ligation required is in direct proportion to the care used in separating 
the fat. If fermentation be watched and the separation be made as soon as 
the casein-precipitate is distinctly present, the centrifugation to a constant 
reading may be quickly accomplished. 

"According to Schlossman, of the albuminoids in woman's milk, 08 per 
cent, are casein, 37 per cent, lacto-albumin, the latter of which is absorbed 
directly. There is, moreover, according to Wroblewski, in the human milk 
another proteid rich in sulphur, poor in carbohydrate and, according to 
some, albumoses and peptones, that also would be directly absorbable. 




Fi<j. 42, 



Woodward's Burette 
for Estimating Proteids. 



126 INFANT FEEDING. 

"Of nucleoli (v. Wittmaack and M. Siegfried, Zeitsch. f. phys. Cliem. 
xxii), there is contained in cows* milk 0.057, in goats' milk 0.110, and in 
woman's 0.124: per cent. In cows* milk the phosphorus of the nucleoli 
amounts to 6 per cent, of the total amount of phosphorus contained in the 
milk, in woman's milk 41.5 per cent. That explains why good cows' milk 
with its inorganic phosphates may give a baby rachitis, while good breast 
milk does not do so at all." (A. Jacob i, Pediatrics, Nov. 1, 1900.) 



Salts. 

We next come to the salts contained in milk, and it is remarkable how 
few analyses have been made to determine the salts or minerals that are 
contained in this fluid. Heidlen's analysis, copied everywhere, seems to be 
the only exhaustive one of the salines in cows' milk made during the past 
century. It seems to me in this case, too, that it is time for the chemist to 
teach us something more. "There probably never was a time, in our era, at 
least, when milk was attracting so much attention as now, and still all our 
chemists are content with the total solids, fats, albuminoids, and sugar — just 
what the butter-makers and cheese-makers want to know. From this much- 
quoted analysis of cows' milk salts we learn that milk contains in various 
proportions the phosphates of lime, magnesia, and iron; the chlorides of 
potassium, sodium, and iron ; and free soda. Eobin gets from human milk, 
in addition to the foregoing, carbonate of lime and soda, phosphate of soda, 
sulphate of soda, and potash. We have no means of knowing how constant 
is the occurrence of any of these salts in milk or under what conditions they 
are modified; we do know, however, from the experiments of Fehling, that 
many of the drugs administered to the milking female are excreted in the 
milk. Therefore, we can safely assume that the saline constituents occurring 
in milk are influenced both by the health and food of the animal. That the 
phosphates are craved for by the milking cow is evidenced by the habit of 
chewing old bones and the like, and that there is a lack of this element of 
food is not to be wondered at when .we see herds of milking cows pastured 
on old, worn-out lands. The practical farmer knows that exhausted pasture- 
lands need, more than anything else, for their rejuvenescence the phosphates, 
and we know that in our nutrition we need them also. The land on which a 
cow is pastured will indicate pretty fairly what Ave may expect to find in 
her milk as salts. We have all noticed the excessive growth of sorrel on 
exhausted land. Can it then be a subject of Avonder that some kind of a 
A r egetable acid should be found in the milk of animals that are obliged to 
include this variety of food in their summer-rations and ?our ensilage or 
spoiled breAvery grains in their Avinter-f eed ? Theodore Hankel's discovery 
of citric acid in coavs' milk to the amount of 0.9 and 1.1 grams per liter is 
just what might be expected." 



SALTS. ENZYMES. STARCH. 127 

Lime-salts in Cows' Milk. Milk curdles under two entirely distincl 
Bets of conditions : (1) it curdles on addition of an acid, and (2) it curdles 
under the influence of rennet (when the reaction of the milk is either neutral 
or slightly acid). The two varieties of curds which may be obtained under 

these circumstances may he denominated "acid curds" and "rennet curds/' 
respectively. Acid curds must inevitably be formed in the stomach after 
milk has been drunk, if the gastric contents are allowed to become acid. 
Such curds (we are familiar with them in ordinary life in the form, for 
instance, of cream-cheese or sour-milk) are probably not sufficiently firm to 
set up digestive disturbances. On the other hand, rennet curds (such as we 
are familiar with in the form of renneted milk and of ordinary cheese) may 
be extremely firm. It is, therefore, in all probability these rennet curds 
which set up the familiar infantile dyspepsia of bottle-fed children. If this 
is so, the facts elicited by Arthus and Pages would appear to be of dominat- 
ing importance in the treatment of these dyspeptic conditions. In order to 
appreciate this correctly the following facts must be attended to: (1) 
rennet-coagulation is delayed and curdling becomes less and less firm as an 
increasing proportion of the lime-salts of the milk becomes precipitated as 
insoluble salts; (2) addition of soluble lime-salts (up to a certain maxi- 
mum) causes increased rapidity of rennet-coagulation, accompanied by in- 
creased firmness of clot; (3) human milk contains 0.03 per cent, of lime; 
(4) cows' milk contains 0.17 per cent, of lime (Bunge). 

Enzymes (Eferont and Prescott). 

The enzymes, soluble ferments, zymases, or diastases are active organic 
substances, secreted by cells, and have the property, under certain conditions, 
of facilitating chemical reactions between certain bodies, without entering 
into the composition of the definite products which result. These substances 
play a very important part in the phenomena of assimilation and of dissimi- 
lation of foods. In fact, most of the foods which occur in Nature at the 
disposition of men, lower animals, or plants are not directly assimilable ; 
they require the intervention of a diastase in order to be transformed into 
substances assimilable and suitable for the formation of new tissues. 

Starch. 

Starch, which serves in the nutrition of almost all living creatures, is 
not directly assimilable, and in the highest organism it undergoes various 
transformations before it can be absorbed. First of all, it encounters the 
enzymes of the saliva, then others in the pancreatic juice, and thus it is 
transformed into maltose and glucose, foods directly suitable for the con- 
struction of tissues. Meat, mink, and white of egg must also be transformed 



128 INFANT FEEDING. 

under the influence of the diastases before becoming assimilable. These 
substances find the enzymes which can act upon them in the gastric and 
pancreatic juices. 

Transformation of Starch. — The cellulose is dissolved, the starch is 
transformed into maltose, part of which is oxidized, and part changed into 
cane sugar by the tissue of the seed. All these transformations, as well as 
the oxidation itself, are produced by the diastases secreted during germina- 
tion. 

One can follow the course of most of these transformations; for ex- 
ample, the solution and transformation of starch. For this purpose an em- 
bryo is separated from the grain and made to develop on a gelatinized must 
in which starch, has been placed in suspension. 

By observing the phenomenon very closely and by examining the starch 
under the microscope, one can see that the grain of starch loses its original 
form; that it is corroded in several places, and that it then liquefies and 
disappears. In the culture liquid one finds substances which did not exist 
before : a sugar, and a nitrogenous substance, the diastase, which is soluble, 
capable of precipitation by alcohol, and can itself produce a transformation 
of starch. 

In the assimilation of albuminoid matter by cells, there occurs a phe- 
nomenon quite analogous to the assimilation of carbohydrates. The albu- 
minoid substances are gradually transformed by the active substances of the 
cells into proteids, peptones, and finally into amides. 

"We have said above that the diastases play an extremely important part 
in the phenomena of dissimilation. The molecules of albuminoid substances, 
hydrated, decomposed, and transformed by the enzymes, are regenerated, in 
the presence of the protoplasm of the cells, by the process of dehydration and 
molecular condensation. The reconstructed molecules undergo new changes ; 
they are again hydrated, decomposed, and at the same time gradually oxi- 
dized. In this phase of the transformation the albuminoid molecule is 
decomposed into urea, glycogen, fatty substances, and amides. These trans- 
formations are also due, in great part, to the active substances secreted by 
the cells. 

Finally, the enzymes are powerful producers of heat; the reactions 
caused by the diastases are exothermic reactions. 

Starch Digestion in Infants. — -A. Jacobi says: "It has long been the 
custom to say that no amylaceous substances should enter into a young 
infant's food because it has from Xature at an early age no ferment capable 
of digesting starch. The saliva of a newly born child — and it is wrong to 
say that there is no saliva at this age — will dextrinize starch, as any one who 
wishes may prove for himself." 

Chemistry of Starch Transformation. — In 1811 Vauquelin found that 
when starch was heated it was changed into a gummy substance soluble in 



PLATE V 




Microscopic Appearance of Raw Starch-granules. 



PLATE VI 




Microscopic Appearance of Starch granules, showin 



ing the effect of Heat. 



CHEMISTRY OF STARCH TRANSFORMATION, 



129 



water. Ivirchof found thai starch boiled with diluted sulphuric acid was 
converted into a sugar. In 1S1 1 he found thai a similar transformation of 
starch was brought about when the vegetable albumin of grain acted upon 
it. This transformation of starch was greatly intensified when the grain was 
malted. Stromeyer, in 1813, discovered the iodine reaction of starch, hi 
L819 tie Saussure isolated the sugar produced by the transformation of 
starch and described its crystalline habit. Biot and Persoz, in 1833, gave 
the name ol' dextrin to the gum formed by the transformation of starch. 
Payen and Persoz gave the name of diastase to the agent in malted grain 
which transformed starch. Leuchs, in 1831, discovered that saliva changes 
starch into sugar. In 1845 Mialhe, in a memoir to the French Academy, 
announced the discovery and isolation of the ferment of saliva. This he 
called animal diastase. He demonstrated the action of malt diastase and 
the action of animal diastase of the saliva upon starch. The transformation 
by the former into dextrin, and the latter into sugar, was identical. It 
was regarded as one of the most important discoveries in chemical physi- 
ology. Mialhe, in 1845, suggested that, since the action of malt diastase and 
of animal diastase upon starch was identical, malt diastase should be em- 
ployed in solving the problem of artificial feeding of infants. The action 
of diluted acid upon starch transforms it into dextrin, maltose, and glucose ; 
but glucose is the end product. The action of diastase, however, wdrether it 
be vegetable (malt diastase) or the animal diastase of the saliva (ptyalin) 
or of the pancreas (amylopsin), transforms starch into dextrin and 
maltose; no glucose is formed, maltose being the end product. It is espe- 
cially to be noted that in the human digestion not until food has passed the 
duodenum is any trace found of dextrose formed by the transformation of 
starch. 

Ozerny and Baginsky, among others, believe that starch is not acted 
upon by the saliva or by the pancreatic secretions, but that the intestinal 
bacteria produced the end products of decomposition, resulting not in sugar, 
but in butyric, lactic, succinic, and propionic acids. According to these 
authors, intestinal bacteria cause the acid reaction and the abdominal dis- 
tention. 



The Additiox of Lime-water, Bicarboxate of Sodium, or 
other Alkalies to Cows' Milk. 

Lime-water is the alkali usually selected for neutralizing the acidity 
It acts by partly neutralizing the acid of the gastric juice, 
so that the casein is coagulated gradually and passes, in great part, un- 
changed into the intestine, to be there digested by the alkaline secretions. 
As it contains only ] /2 grain of lime to the fluidounce, the desired result 
cannot be attained unless at least a third part of the milk-mixture be lime- 
water. Instead of lime-water, 2 to 4 grains of bicarbonate of sodium may 



130 INFANT FEEDING. 

be added to each bottle, or, better still, from 5 to 15 drops of the saccharated 
solution of lime. 

This solution is made in the following way : — 

IJ Slaked lime 1 ounce 

Refined sugar, in powder 2 ounces 

Distilled water 1 pint 

Mix the lime and sugar by trituration in a mortar. Transfer the 
mixture to a bottle containing the water, and, having closed this with a cork, 
shake it occasionally for- a few hours. Finally separate the clear solution 
with a siphon and keep it in a stoppered bottle. 

Bicarbonate of Soda Solution {Baking Soda). — Take 1 grain of soda 
bicarbonate to % ounce of water. Or 1 drachm of soda bicarbonate to 1 
quart of water. This is the proper strength used for diluting milk. 

Quantity to be Used. — One tablespoonful of the last-named solution 
equals in strength 1 tablespoonful of ordinary lime-water. 

Both lime-water and soda-bicarbonate solution should be kept in very 
clean, well-stoppered bottles and in a cool place. 

The teaching that lime-water should be added to render cows' milk 
alkaline and thereby resemble human milk, has been studied by Kerley, 
Gieschen, and Meyers, whose conclusions are very interesting. They say 
that : — 

1. Breast-milk and cows' milk are both acid. 

2. The litmus-paper test for milk is unreliable because of the varia- 
tion in the quality of litmus paper, and the litmus taking part in the 
reaction and not acting as an indicator. 

3. The effect of adding lime-water or bicarbonate of sodium to feeding 
is to retard or inhibit the formation of curds by rennet. 

4. The teaching that lime-water, bicarbonate of sodium, or carbonate 
of potassium should be added to fresh milk or feedings simply because they 
are antacids is erroneous. 

5. The addition to milk or feedings of alkalies or salts that become 
alkaline in solution is an empirical method of aiding digestion by prevent- 
ing the formation of dense curds that would slowly leave the stomach and 
be difficult of digestion in the intestine. 

In one respect I do not agree with them, and that is in regard to the 
addition of bicarbonate of potassium. In weak infants, especially in maras- 
mic cases and in those infants in which "milk colic" appears one or two 
hours after being fed with cows' milk, I have found that by the addition 
of 10 to 15 grains of bicarbonate of potassium to each feeding improve- 
ment was invariably noted. I have not found this improvement when 
bicarbonate of soda or lime-water was added. 



cream in home modification. 131 

Cream. 

When food contains too little fat, or its equivalent (cream), we have 
fat-starvation, which is soon manifested by symptoms of rickets. One of 
the earliest symptoms of rickets is constipation, showing deficient muscular 
tone: a distinct atony of the bowel. 

This can he remedied by the addition of fat or cream to the food. 
Some children are benefited by giving them codliver-oil, butter, or olive-oil ; 
thus, it is plain that each one desires to remedy the deficiency of fat in his 
own manner. 

In buying cream from small milk-stores one can make a rough guess 
at the proportion of fat in cream by its thickness. A 50-per-cent. cream at 
the ordinary temperature of the room runs from a jug slowly and in a 
thick stream, almost like thick mucilage, whereas a 16 per cent, cream 
runs almost as freely as milk. This is, however, a crude way of estimating 
the difference between poor and rich cream. It is a very important point 
to know exactly what percentage of cream we are using, for such mixtures 
like Biedert's, in which 1 ounce of cream is mixed with 3 ounces of water, 
may agree very well when we use a 16 or 20 per cent, cream, but might be 
disastrous if we use a cream containing 40 per cent, of fat. Such infants 
would not tolerate this rich cream, and might have troublesome vomiting. 

Cream for Home Modification. — Ordinary Cream: This is made by 
setting milk at night and skimming it in the morning; it is called gravity, 
or skimmed, cream, and contains 16 per cent, of fat. 

Twelve Per Cent. Cream. — Obtained in the city by using equal parts 
of ordinary (20 per cent.) centrifugal cream and plain milk. In the 
country we must use 2 parts of ordinary skimmed, or gravity, cream (16 
per cent.) with 1 part of plain milk, or by taking the top layer of milk, 
after it has stood five or six hours, by means of siphoning. 

Eigh t per cent, cream is obtained in the city by diluting 1 part of cen- 
trifugal (20 per cent.) cream with 3 parts of plain milk; in the country, 
by using 1 part of gravity cream and 2 parts of plain milk, or by using the 
top layer of milk that has been standing five or six hours, siphoning it off. 

How to Procure Cream. — Set aside the ordinary quart bottle of milk 
on the ice for several hours (from six to eight hours) to allow the cream to 
rise. After the cream has risen draw the milk from the bottom of the 
bottle; this can be accomplished by means of a siphon. 

To make the siphon get a piece of glass tubing 21 inches in length and 
a quarter of an inch in caliber. This can be procured in any drug store. 
German glass is less liable to crack than American glass. If the glass tubing 
is longer than 21 inches make a small scratch in it, after measuring off 21 
inches, with a three-cornered file, then grasp the glass tubing between the 
fingers and opposing thumbs of both hands, having the thumb-nails touch- 



132 



INFANT FEEDING. 



ing each other on the side of the glass just opposite to the scratch. On 
attempting to hend the glass tuhe it will break smoothly across, and if 
there are any sharp edges they can be smoothed by rubbing down with the 
file. 

To bend the glass tube to the V shape, hold it in the flame of an ordi- 
nary gas jet or alcohol lamp for a few moments, twirling the glass rod until 
it softens sufficiently to allow it to be bent to the required angle. The tube 
should be warmed gradually at first, and then put right into the flame. It 
is better in bending the glass to make one arm of the siphon a few inches 
longer than the other. 

In using -the siphon hold it with the angle down, fill it with water, 
and close the long arm with the tip of the finger; then, keeping the finger 
applied to the long end, turn the siphon with the angle up, and introduce 




Fig. 43. — Chapin Cream Dipper. 

the short arm into the bottle of milk, letting it rest upon the bottom. On 
removing the finger, the milk will flow through the tube, and continue to 
do so until the bottle is empty. It is, therefore, necessary to watch the 
layer of cream, so that the siphon can be lifted out of the bottle just before 
the cream reaches it. There will thus remain in the milk-bottle all of the 
cream and a small portion of the milk, the latter depending upon the ex- 
pertness of the persou using the siphon. 

A simpler method of obtaining the cream is by the use of a cream 
dipper (see Fig. 43). This can be purchased at any large drug store. The 
illustration explains itself. 

To Pasteurize the Cream. — Take a clear glass bottle having a neck not 
very wide; fit into the same a perforated cork with a chemical thermom- 
eter registering up 212 = F. The bulb of the thermometer should come 
within half an inch of the bottom of the bottle. The cream is put into the 



MODIFICATION OF MILK. 



133 



bottle, and the cork carrying the thermometer is inserted; the bottle is 

then placed in a pot containing a couple of inches of warm water and 
allowed to heat on the stove. The thermometer should be watched until 
it reaches 140, taking care that it does not go above 140. When the ther- 
mometer has reached this point, set the pot back on the stove where it will 
cool off, and allow it to remain there for twenty minutes. At the end of 
this time substitute a plug of absorbent cotton for the cork containing the 
thermometer. Great care must be taken to keep the absorbent cotton dry. 
Cream thus prepared is pasteurized, and will keep sweet and fresh for 
twenty-four hours without being kept on ice, and all that is necessary in 
removing a portion from the bottle is to be sure that the cotton plug does 
not become moist, or, if it should, to replace it with a dry piece at once. 

To Clean the Glass Siphon. — It is advised to fill it with water imme- 
diately after using it, and the ordinary tube-brush having eighteen 
inches of wire added to it will permit thorough cleansing. Xothing, how- 
ever, will be found as good as thorough boiling in plain water to which a 
pinch of soda has been added. 

Modification of Milk. — It has been shown previously that the percent- 
ages of fat in woman's and in cows' milk are about the same, that the 
quantity of sugar is rather lower in cows' milk, and that the quantity of 
casein and albumin is greater in cows' milk, as is also the ash. Experience 
lias shown that cows' milk must be diluted before it can safely be fed to 
infants. Simply diluting the milk reduces the percentages of fat and sugar 
too much ; so that the practice of adding cream and sugar has arisen, but the 
processes that have been advocated for obtaining the desired additional 
quantities of fat and sugar have been too complicated for general use. 

The top 9 ounces of a quart of milk on which the cream has risen will 
be about three times as rich in fat as the whole milk, the top 15 or 16 
ounces will be about twice as rich as the whole milk, while the other 
ingredients remain about the same as in whole milk. 

For babies under three months of age the top 9 ounces of a quart of 
milk on which the cream has risen should be diluted from three to ten 
times and 1 part of sugar added to 25 parts of food. 

For babies three to six months old the top 16 ounces of a quart of 
milk on which the cream has risen should be diluted two or three times 
and 1 part of sugar added to 25 or 30 parts of food. 

For babies six to nine months old the top 20 ounces of a quart of 
milk on which the cream bus risen should be diluted one-half to one time 
and 1 part of sugar added to 50 parts of food. An even tablespoonful of 
granulated sugar equals half an ounce. 

By following this method the infant commences on weak mixtures 
that show about the same composition and variations as woman's milk 
and gradually takes food richer in casein until plain milk is reached. 



134 



INFANT FEEDING. 



The diluents used are water, gruels, or dextrinized gruels, which are 
simply ordinary gruels the starch of which has been converted into soluble 
forms, leaving the cellulose and proteids of the cereal in a finely divided 
state. The effect of the different diluents will be mentioned farther on. 



Table No. 25. — Feeding-table. 

(Geo. C. Carpenter, Loudon.) 



Age. 


Intervals of 
Feeding. 


Number of 
Times in 
24 Hours. 


Average Amount 
Each Feeding. 


Average in 
24 Hours. 


1st week 

1st month ...... 

2d month ...... 

3d and 4th months . . 
5th and 6th months . . 


2 hours 

2 hours 
2£ hours 

3 hours 
3 hours 


10 

8 
8 
7 
6 


1 oz. 
1£ to 2 oz. 

3 to4oz. 

4 to 5 oz. 
6 to 7 oz. 


10 oz. 

12 to 16 oz. 
20 to 30 oz. 
30 to 35 oz. 
34 to 40 oz. 



Biedert's Cream Mixtures. 1 — The following formulae are from the 
fourth edition of his book on "Infant-feeding," published in 1900 : — 

Table No. 26. 





Formula. 


Cream. 


Water. 


Milk-sugar. 


Milk. 


Casein. 
Per Cent. 


Fat. 
Per Cent. 


Sugar. 
Per Cent 


1st month . 


I. 


4 oz. 


12 oz. 


4^ dr. 




0.9 


2.5 


5 


2d month . 


II. 


4 oz. 


12 oz. 


4£dr. 


2oz. 


1.2 


2.6 


5 


3d month . 


III. 


4 oz. 


12 oz. 


4^ dr. 


4 oz. 


1.4 


2.7 


5 


4th month . 


IV. 


4 oz. 


12 oz. 


4^ dr. 


8oz. 


1.7 


2.9 


5 


5th month . 


V. 


4 oz. 


12 oz. 


4* dr. 


12 oz. 


2.0 


3.0 


5 


6th month . 


VI. 


• • 


8oz. 


3 dr. 


24 oz. 


2.5 


2.7 


5 



According to recent milk analyses, it is necessary to take 6 per cent., 
which is equivalent to 5% drachms of sugar to 12 ounces of water. It has 
also been shown that cane-sugar in the same quantity as milk-sugar can be 
used. In using Formula 5, especially if an infant is constipated, it is ad- 
visable gradually to substitute milk for the water; thus we take away 1 
ounce of water, and add 1 ounce of milk, until our formula is : — 



Cream. 
4 ounces. 



Sugar-toater. 
4 ounces. 



Milk. 
20 ounces. 



And gradually arrive at a whole milk feeding; in other words, give pure 
cows' milk undiluted. Biedert claims that frequently diluted cows' milk was 
not well borne, especially on weak stomachs, and the change to the cream 
mixture resulted in decided benefit. He believes that the cream mixture is 
assimilated far better than the diluted milk mixtures not containing cream. 
Thus he claims that the cases of constipation alternating with diarrhoea 
and lastlv mucous enteritis are those in which the cream mixture will render 



Biedert's cream is sold in this country under the name of Ramogen. 



llll'] RIPENING OF CREAM. 135 

satisfaction; but lie advises that a definite rule must prevai] regarding the 
amount of fat contained in the cream, and furthermore that an 8 to 10 

per rent, cream be used. 

Biedert's Directions for Making Cream. — From 1 to 2 quarts of 
milk are put into a broad jar (glass) on the ice, for no longer than two 
hours, lie then removes with a flat spoon from o 1 /} to 7 ounces of the 
thin white creamy layer over the bluish mass of milk. In removing the 
above quantity a small portion of the milk will be removed with it. In 
cases of severe constipation Biedert insists on removing pure cream. 

The above Formula I is for the first month, Formula II is for the 
second month. Formula III is for a child from three to four months, For- 
mula IV is for fourth to fifth month, Formula V is for the sixth to seventh 
month, and Formula VI is for the eighth to tenth month. 

It is understood that, while feeding, the general condition of the child 
is the criterion, and thus we shall frequently be compelled to change the 
formula for individual requirements, some infants requiring far more cream 
than the above-mentioned formulae give them for their age and their weight, 
whereas the great majority will require a modification of far less cream 
than the above-given formulae for their age and weight. 

The indiscriminate feeding of cream, to strengthen the baby, cannot 
be too strongly condemned. Many a dyspeptic owes his trouble to over- 
feeding by a too good mother or nurse. When cream is added, and the pro- 
portion of fat or proteid is too large, vomiting will result. Stuffing delicate 
children with cream, regardless of their digestive power, cannot be too 
strongly condemned. When improper food is given, and the infant's stom- 
ach is overtaxed, the excess of food irritates and may cause vomiting. If, 
however, the food remains, then the gastric mucosa is inflamed by bacterial 
fermentation of stagnant food. This may result in diarrhoea or in fermen- 
tative gastritis, and cause chronic enlargement of the stomach. 

The Ripening of Cream. 1 

From the following table it will be seen that the number of bacteria 
in the unripened cream is very much more variable than that present in the 
ripened cream. In the unripened cream the number was sometimes as small 
as 1,000,000 per cubic centimeter, and in one case it was so small that it 
could not be determined with the high dilutions which were used. At the 
other extreme we have one sample of unripened cream collected in February 
with 2-20.000,000 bacteria per cubic centimeter. In the other experiments 
the figures range between these. The significance of this fact is, of course, 
simply that the cream as collected in the creamery, which w r e speak of as 
unripened. is really in different stages of ripening by the time it reaches 

1 By Conn and Esten (Storrs Agricultural Experiment Station). 






136 



INFANT FEEDING. 



"the creamery. The samples with large numbers of bacteria are already well 
ripened, while those with small numbers have only begun their ripening 
process. 

Table No. 27. — Number of Bacteria in Unripened and Ripened Cream. 







Temperature 


In 


In 




Date. 


During Time of 


Unripened 


Ripened 


Remarks. 






Ripening. 


Cream. 


Cream. 










Per c. c. 


Per a c. 




October 


28, . 




125,000,000 


350,000,000 




May- 


22, . 


64° for 20 hours 


56,000,000 


354,000,000 




May 


26, . 


64-68° for 20 hours 


60,000,000 


320,000,000 


Good aroma 


May 


29, • 


66° for 18 hours 


186,000,000 


295,000,000 


Good aroma, gas 


July 


2,* 


60-70° for 16 hours 


214,000,000 


380,000,000 


Good aroma 


July 


5,*. 


63-65° for 16 hours 


178,000,000 


392,000,000 


J Good aroma, thick. 
\ slightly acid 
Good aroma, acid 


July 


12,*. 


71° for 17 hours 


67,000,000 


190,000 000 


July 


16,* . 


71° for 16 hours 


134,000,000 


243,000,000 




July 


19, . 


71° for 14 hours 


75,000,000 


286,000,000 


Slow ripemng 


July 


22, . 




115,000,000 


428,000,000 




October 


13, . 


68° for 18 hours 


72,000,000 


291,000,000 




( >ctober 


30, . 


60-65° for 28 hours 


107,000,000 


199,000,000 




November 


3, . 




39,000,000 


234,000,000 




December 


8, . 


60-70° for 29 hours 


4,000,000 


238,000,000 




December 11, . 


60-70° for 24 hours 


35,000,000 


200,000,000 




October 


19, . 


60-70° for 24 hours 


39,000,000 


380,000,000 




October 


26, . 


60° for 21 hours 


115,000,000 


297,000,000 


Ripe when collected 


November 


2, . 




158,000,000 


355,000,000 





♦ Hot Weather. 



The number of bacteria in the ripened cream varies far less. The 
smallest number found was 50,000,000 ; the largest number, 578,000,000. 
While this difference is of course in actual numbers a large one, the pro- 
portionate difference is very much less than in the unripened cream; one 
sample of unripened cream, for instance, containing two hundred and twenty 
times as many bacteria as another sample, while the largest number in the 
ripened cream was only about eleven times as great as the smallest number. 

The only conclusions of any significance from these facts are that the 
cream received by creameries is in various stages of ripening, and, secondly, 
that the number of bacteria in ripened cream does not run much over 500,- 
000,000 per cubic centimeter. In the well-ripened cream this number is 
rarely surpassed. 

General summary of the conclusions which were drawn from the long 
series of experiments in regard to the actual bacteriological development 
that occurs during the normal ripening of cream: — 

1. Milk as it is drawn from the cow contains great quantities of bac- 
teria ; most of these are miscellaneous forms of liquefying bacteria and 
other non-acid species. At the outset the number of acid bacteria is very 
small. 



BACTERIA IN CREAM. 137 

v. All species of bacteria increase during the setting of the milk for the 
separation el' the cream. 

3. For a few hours the alkaline bacteria and the others which have 
been included under the head of miscellaneous forms increase quite rapidly, 
while the lactic bacteria are hardly evident. 

4. After about twelve hours the lactic bacteria have increased so much 
a- to he as numerous as the others, and from this time on they continue to 
increase with great rapidity until a maximum is reached at about forty-eight 
hours; after this the numbers gradually decrease and they finally practically 
disappear. 

5. The ripened cream contains prodigious numbers of bacteria, larger 
numbers than are known in any other natural medium. They are, however, 
nearly all lactic bacteria. 

6. After the first twelve hours all species of bacteria except the two 
lactic species decrease in relative numbers and finally absolutely disappear. 

7. The cream which is received by a creamery is already partly ripened, 
as indicated by the immense numbers of bacteria it contains. All of the 
changes which occur in the cream under the influence of the miscellaneous 
bacteria have already occurred, and the ripening that takes place in the 
creamery is due wholly, or almost wholly, to the growth of the acid bacteria. 

8. A ripened cream is almost a pure culture of acid bacteria, but this 
does not mean that the ripening has been produced by these acid bacteria 
alone. 

9. That the lactic bacteria play an important part in the ripening is 
perfectly evident; that they are the sole cause of the changes occurring in 
the ripening is not so evident. 

10. The peculiar flavor of June butter, which is so much desired by 
the butter maker, is not clue to the development of the common lactic bac- 
teria. Butter ripened during the winter months develops the two species of 
lactic bacteria as abundantly and as quickly as does that ripened in June, 
but the flavor does not make its appearance. In the last three experiments 
recorded the June flavor was very noticeable in the cream, but the develop- 
ment of the acid bacteria, or the two species referred to, was practically the 
same as in all of the previous experiments. The June flavor, therefore, 
cannot be due to these common lactic bacteria. 

11. To what this June flavor is due we are not as yet satisfied. Whether 
it will prove to be due to the large growth of miscellaneous bacteria during 
the first few hours of ripening, or whether it is due to a difference in the 
chemical nature of the cream, remains for further experiments to decide. 

Tor-^itT.K. 

Top-mill; is obtained directly from fresh milk by the so-called "gravity 
process." Cream contains a great deal of fat, usually three-fifths of cream 



138 INFANT FEEDING. 

is fat; this floats on the surface of the watery milk. If a quart bottle of 
the average city milk is put into ice-water or upon ice in the refrigerator, 
and removed after four or Ave hours, we can skim off from the top about 
10 ounces of an 8 per cent, cream ; after six hours about 6 ounces of 12 
per cent, cream. This I shall speak of as top-milk. Frequently, instead of 
skimming the cream, the lower portion is siphoned off, leaving the cream in 
the glass bottle. "When cream is removed by a centrifugal machine, it is 
known as centrifugal cream. It can be separated much more quickly than 
so-called gravity cream, which must rise naturally and slowly from milk 
that is allowed to stand. 

My experience with top-null- feeding lias been bad. Infants fed on 
top-milk diluted with water have gradually shown dyspeptic symptoms, and 
it was necessary to give the stomach absolute rest by using very dilute solu- 
tions of milk and rice or barley water. An interesting case of top-milk 
feeding came to my office recently : — ■ 

Child three months old having stools containing enrds and greenish mucus. 
All gastric disturbances were present. Vomiting followed each feeding. When the 
top-milk was stopped the gastric symptoms subsided. 

My rule has been to give bottle-fed infants first a very minute quantity 
of milk, 1 part of milk with 3 or 4 parts of water. If the same is assimi- 
lated, I increase the quantity of milk and decrease the water from week to 
week. Top-milk or cream feeding should be used cautiously. I believe 
that more cases of dyspepsia are caused by this heavy form of feeding than 
by any other method of feeding. 



CHAPTEE III. 
home modification of milk. 

Bottle-feeding or Hand-feeding. 

The following utensils arc required for the home modification of 
milk: — 

Two-quart pitcher, j 

Funnel, V glass or porcelain. 

One large spoon, J 

One dozen 4-ounce bottles (later substitute 8-ounec bottles). 

One dozen anti-colic nipples. 

One box non-absorbent cotton. 

One saucepan (for heating milk). 

One high saucepan (for warming bottle before feeding). 

General Eules for Bottle-feeding. 

No set rule can be given for all infants. Each infant's desires must 
be studied. The stomach capacity of one infant may be 6 ounces at the age 
of two months, while another equally healthy infant will be satisfied with 
Jf ounces at one feeding. 

Table > t o. 28. 



Age of Child. 


Frequency or 

Interval of 

Feeding. 


Number of 

Feedings in 

24 Hours. 


Average Amount 

for 

Each Feeding. 


Average Amount 

in 

24 Hours. 


From birth to 
1 month 


2 hours 


10 


1 to 2 
ounces 


10 to 20 
ounces 


1 to 2 months 


2} hours 


8 


3 to 4 
ounces 


24 to 32 
ounces 


2 to 4 months 


3 hours 


6 or 7 


3\ to 5 
ounces 


24 to 35 
ounces 


4 to 6 months 


3 hours 


6 


5 to 7 
ounces 


30 to 42 

ounces 


6 to 9 months 


3} to 4 
hours 


5 


8 ounces 


40 ounces 


9 to 12 months 


4 hours 


4 


8 ounces 


32 ounces 


lyear 


4 hours 


4 


8 ounces 


32 ounces * 



l See article on "Additional Foods During the Nursing Period," In Chapter on "Breast-feeding.' 

(139) 




140 INFANT FEEDING. 

These individual peculiarities must be taken into consideration when 
estimating the quantity of food for each meal. An infant that cries 
after taking its bottle, and puts its fingers to its mouth and whines and 
frets, if otherwise normal, is generally underfed. When children are 
underfed they usually have greenish, spinach-like stools. 

Formula Xo. 1 (for a 'child from birth to one month old) : — ■ 

R< Raw cows' milk 4 ounces 

Barley water 1 16 ounces 

Granulated sugar 1 ounce 

Mix thoroughly. Heat in a new saucepan until steam rises. Continue steam- 
ing at same temperature ten minutes. Divide into ten bottles (2 ounces each). 
Insert in the necks of the bottles large cotton stoppers. Place the bottles in a 
refrigerator, but not on ice. Warm before feeding, by placing bottle into a deep 
saucepan of hot water until the food reaches the body temperature. 

Formula Xo. 2 (for a child from one to two months old) : — 

R. Raw cows' milk 7 ounces 

Barley water 20 ounces 

Granulated sugar 1 1 / 2 ounces 

Divided into eight bottles, each bottle containing about 3 ounces. Feed every 
two and one-half hours. 

Formula Xo. 3 (for a child from two to four months old) : — 

I£ Raw cows' milk 12 ounces 

Barley water 23 ounces 

Granulated sugar 1 Vs ounces 

Divide into seven bottles, each bottle containing about 5 ounces. Feed every 
three hours. 

Formula Xo. 4 (for a child from four to six months old) : — 

1$. Raw cows' milk 22 ounces 

Barley water 20 ounces 

Granulated sugar 1 ounce 

Divide into six bottles, each bottle containing about 5 1 / 2 ounces. Feed every 
three hours. 

Formula Xo. 5 (for a child from six to nine months old) : — 

R. Raw cows' milk 28 ounces 

Barley water 12 ounces 

Granulated sugar 1 ~/ 3 ounces 

Divide into five bottles, each bottle containing about 8 ounces. Feed every 
three and one-half hours. 

1 For formula of barley water, and other diluents, see "Dietary." 



RULES FOR BOTTLE-FEEDING. 1 | 1 

Formula No. 6 (for a child from nine to twelve months old): — 

U Kaw cows' milk 27 ounces 

Barley water 5 ounces 

Granulated sugar 1 V a ounces 

Divide into four bottles, each bottle containing 8 ounces. Feed every four 
hours. 

Formula No. 7 (for a child over 1 year of age): — 

I^ Raw cows' milk 32 ounces 

Granulated sugar 1 2 /a ounces 

Divided into four bottles, each bottle containing 8 ounces. Feed every four 
hours. 1 

The modification of cows' milk with the addition of Eskay's albu- 
minized food has served me very well. The food has a decided mechanical 
effect on the casein, splitting it up, thus rendering it more flocculent. To 
children over five months I usually give the following: — 

1^ Raw cows' milk 5 ounces 

Barley water 3 ounces 

Eskay's albuminized food 1 teaspoonful 

Granulated sugar 1 teaspoonful 

Mix the ingredients thoroughly and heat in a saucepan until the steam rises. 
It is important to use none but fresh milk, and milk that contains at least 4 per 
cent, of fat. If less fat exists in the milk a tendency to constipation may arise. 

The addition of a teaspoonful of calcined magnesia or a teaspoonful 
of the fluid milk of magnesia, sold in drug stores, given with the morning 
bottle, will correct constipation. From month to month as the child in- 
creases in weight and assimilates the food, we can add more of the Eskay's 
food, more cows' milk, and reduce the barley water. 

The following formula? have proven very successful and are copied 
from my book on "Infant-Feeding in Health and Disease" 2 (Chapter XXI, 
p. 152):— 

Other Rules for Bottle-feeding. 

For a Child at Birtli. Formula 1. — The new-born infant's food should 
consist of (home modification): — 

Formula for Home Use. 

Fat 1.0 Cream 2 ounces 

Sugar 5.0 Milk 2 ounces 

Proteids 0.75 Lime-water 1 ounce 

Reaction alkaline. Water 15 ounces 

Milk-sugar 6 3 / 4 drachma 

1 Sec article on '"Additional Foods During the Nursing Period," in the chapter 
on ''Breast-milk." 

2 Louis Fischer: "Infant Feeding in Health and Disease," Third Edition, F. A. 
Davis Company. 



142 INFANT FEEDING. 

The above formula (1) is to be divided into 10 feedings of 2 ounces 
each, or GO cubic centimeters each, and should be heated for twenty 
minutes to 140° ¥., though Russell, of "Wisconsin, has proved by experi- 
ment that tubercle bacilli are destroyed at 140° F., which temperature 
may answer when a good source of milk is found. 

The cream must contain at least 10 per cent, of fat. This is known 
as a decimal cream, and can be referred to under the heading of "Cream 
for Home Modification." 

Child 1 Monti. Formula 2.— Take of:— 



Fat 


... 2.0 


Sugar 


... 5.0 


Proteids 


. .. 0.75 


Lime-water . . . 


... 5.0 



Cream 4 ounces 

Lime-water 1 ounce 

Water 15-25 ounces 

Milk-sugar 6 3 / 4 drachms 



The above quantity is to be divided into ten feedings, and heated for 
twenty minutes to 140° F., and the infant to be fed once every two hours. 
In Formula 2 we have added more cream and purposely left out the milk. 
If the infant thrives on this mixture, then we can substitute 1 ounce of 
milk instead of 1 ounce of water. Some children will not be satisfied with 
less than 3 to 4 ounces; there is no reason why they should not receive 
the above quantity if their general condition warrants it. 

After the end of the second month the quantity of food can be 
increased if the infant's appetite, sleep, stools, and general condition war- 
rant it. Thus, instead of feeding a bottle of Formula 2, we simply add 1 
ounce of milk for the third month to Formula 2. Frequently the addition 
of 1 or 2 ounces of sterile water to the formula will give a larger bulk and 
satisfy the infant. As every infant's appetite and gastric capacity is 
different, we must carefully note the condition of the baby after its 
feeding before resorting to fixed rules. 

At Four Months. Formula 3.— Take of:— 

Fat 3.5 Cream 7 ounces 

Sugar 6.5 Milk 1 ounce 

Proteids 1.5 Lime-water 1 ounce 

Lime-water 5.0 Water 25-32 ounces 

Milk-sugar 6 1 / i drachms 

Divide into eight bottles; heat as above to 140° F.; feed every three hours. 

From Nine to Twelve Months. Formula Jf. — Take of: — 

Fat 4.0 Cream 8 ounces 

Sugar 7.0 Milk 7 V 2 ounces 

Proteids 3.0' Lime-water 1 ounce 

Lime-water 5.0 Water 20-30 ounces 

Milk-sugar 6 3 / i drachms 

The above to be divided into five feedings, heated to 140° F., and one bottle fed 
every four hours. 



ILLUSTRATIVE BOTTLE FEEDING. 



143 



Clinical Illustrations ok How to Feed (from the Author's Private 

Records). 

Case I. — 15a by V., was referred to me for treatment April 3, 1901. 

The child was three and a half months old at time of commencing treatment, 
and weighed 8 pounds and 10 ounces. 

History: Breast-fed about two weeks; since then fed on milk diluted with 
water and milk-sugar; food was steamed forty minutes. Child had always been 
constipated, always cries, and suffers with colic. 

Gave barley and condensed milk with lime-water; child seemed to do well; 
weight was about 10 pounds. After several weeks cream was added to the food. 
After this addition of cream the child vomited and cried, had severe colic, was 
restless by day, and had insomnia at night. Its bowels were so disturbed that all 
milk was stopped. Barley-water was the only food tolerated. Then cereal milk 
was prescribed. The cereal milk was not retained; child vomited after each feeding, 
then was constipated, which alternated with greenish, dark stools. Infant was 
emaciated; the stools contained mucus. 

Physical Examination: Very emaciated child; temperature, 100° F.; abdomen 
distended, very flatulent; skin dry, elasticity lost; herpetic eruption on lips and 
around anus; pulse, 140 and feeble; throat clean; lungs normal; heart-sounds, 
very feeble; left inguinal hernia. 

Diagnosis: Athrepsia, resulting from chronic gastric catarrh. 

Food ordered: — 

Pure cows' milk 2 ounces 

Oatmeal-water 2 ounces 

Granulated sugar Va teaspoonful 

Peptogenic powder Va teaspoonful 

Feed every three hours. Alternate with: — 

Pure cows' milk 2 ounces 

Barley-water 2 ounces 

Granulated sugar Va teaspoonful 

Peptogenic powder f. . . . V 2 teaspoonful 

Heat this mixture slowly for ten minutes, then boil one minute. 

Mother reports that the child takes food well, stools are yellow, and child 
passed a good night, but still has eructations and seems colicky. The food was 
continued, and the child gained ten ounces in seven days. 

Weight, April 3 8 pounds and 10 ounces 

Weight, April 10 9 pounds and 4 ounces 

Weight, April 17 9 pounds and 8 ounces 

Weight, April 24 9 pounds and 14 ounces 

Weight, May 1 10 pounds and 4 ounces 

Weight, June 3 12 pounds and 5 ounces 

Weight, June 15 13 pounds and 12 ounces 

Weight, Hoc. 20 19 pounds 

Extract of malt was ordered, Va teaspoonful three times a day. Every week 
the formula was changed, commencing with: — 

Milk 2 ounces ~> 

Barley-water or oatmeal- water 2 ounces j Formula J 



144 



INFANT FEEDING. 



} 



Formula II 



Formula III 



One week later I ordered: — 

Milk 2 Va ounces 

Barley-water or oatmeal-water 2 V 2 ounces 

Feed every three hours. 

Raw milk 3 ounces 

Barley-water or oatmeal-water 3 ounces 

Peptogenic powder 2 teaspoonfuls 

Granulated sugar Va teaspoonful 

Feed every three or three and one half hours. 

I ordered this infant to be awakened by day for feeding, but not to be disturbed 
at night. When the child cried after feeding when 5 months old, instead of giving 
Formula III, I ordered: — 

Raw milk 4 V2 ounces 

Barley-water 2 1 / 2 ounces 

Peptogenic powder Va measure 

Granulated sugar V2 teaspoonful 

The above for one feeding. Feed every three or three and one-half hours. Sub- 
stitute oatmeal-water for barley-water every other day. 



Formula IV 



Formula V 



Milk 5 Va ounces 

Barley-water 2 ounces 

Peptogenic powder Va measure 

Granulated sugar V2 teaspoonful 

Alternate with oatmeal-water. Feed every three and one-half or four hours. 

Case II. — Dorothy L. F., eleven months old, was referred to me for treatment 
on March 18, 1901, by Dr. H. J. 

The history elicited was: The baby is still nursing and appears undersized, 
?ery ansemic, and poorly developed. No evidence of teething; cannot walk nor talk. 
Has had summer complaint. Recently suffered with constipation. Had diarrhceal 
stools some time ago; stools were greenish in color, and contained curds and mucus. 
Has had a cough lasting three weeks; also sniffles. A restless sleeper, rarely sleep- 
ing more than one-half hour at a time during the day. Is frequently very raw be- 
tween thighs and on buttocks. Child is very flatulent. 

Physical Examination: A very frail child; large abdomen; slight evidence 
of rickets; very feeble heart-action; lungs normal; spleen palpable; liver very 
much enlarged; colon distended, tympanitic on percussion; muscles of extremities 
very flabby; bones very small; epiphyses of long bones very much enlarged; tongue 
coated; throat normal; some adenoids. 

Specimen of breast-milk sent to chemist for examination showed: — 

Quantity, about 2 ounces, or 60 cubic centimeters. 
Reaction slightly alkaline. 

Specific gravity 1.03105 

Fat 1.22 

Sugar „ 7.07 

Proteids 0.98 

Shows low fat and low proteids. 

The baby weighed about 4 '/ 2 pounds at birth, and weighed between 12 and 13 
pounds when G months old. It now weighs naked about 16 pounds. 



[LLUSTRATIVE BOTTLE-FEEDING. 14f) 

From the history i learned thai the mother menstruated while nursing Bince 
her child was 4 months old. The infant's restlessness was evidently associated with 

this condition. 

The Btudy of the chemical examination of the breastrmilk which this child 
received easily explains the poor development, the proteids being less than 1 per cent., 
besides a very low percentage of fat being also partly responsible. 

Treatment: Absolute weaning from the mother's breast. 

Pure coirs' milk, warmed to feeding temperature, or about 100° F., 6 ounces to 
be given at each feeding. Feed every four hours; strict observance of interval of 
feeding and careful attention to sterility of everything coming in contact with food 
or utensils to be used. 

.Medication: One half teaspoonful of malt-extract given three times a day. 

This food was not well assimilated, so I ordered 1 _> measure of peptogenic milk- 
powder to be added to each ounces of raw milk. Gradually heat in a saucepan 
over a small flame for five minutes, then heat more rapidly and boil for about ten 
seconds. Repeat every four hours. Prepare each bottle separately. Do not warm 
the food a second time, if the bottle is not emptied at one feeding. 

My record three days later shows : Had a very good night. Better appetite, 
formerly took only 3 to 4 ounces, now takes almost 5 ounces. Did not moan last 
night. 

March 27th: Child looks better; bowels moved twice naturally, and have a 
yellowish color, but no curds. Temperature. 99° F. ; pulse, 120; respiration, 36. 

This feeding was continued for about three weeks, and owing to good results, 
no changes were made. 

This is the mother's report, which I copy: — 

"April 8th: Had a good night; slept from 10.30 p.m. to 6.30 a.m. continuously. 
Bowels are splendid, yellow; three stools yesterday. Has a slight irritation of 
genitals; seems to be fumbling with the parts." Examination showed vulvitis, irrita- 
tion due to scratching, slight eczematous intertrigo. 

Diet ordered: To continue raw milk modified with peptogenic powder; in ad- 
dition thereto beef-soup thickened with either hominy, sago, or farina. Feed two 
hours after milk-bottle once a day, preferably about noon. Give the child the white 
of a raw egg with sweetened water every other dav. The child received soup, alter- 



■-■-* 



soup. 



nating the next day with the white of egg, in the following manner: — 

Warm ran: milk, modified with peptogenic. 6 ounces at 6 a.m. 

Milk, peptogenic 6 ounces at 10 a.m. 

Soup, thickened 6 ounces at 12 Xoon 

Milk, peptogenic 6 ounces at 2 p. m. 

Milk, peptogenic 6 ounces at 6 P. m. 

This food was well borne; the child gained. To improve the appetite 1 minim 
of nux vomica was ordered three times a day. before three feedings. 

Warm or raw milk, modified by heating with peptogenic as directed above: — 

Raw milk, 6 ounces 6 a. m. 

Raw milk. <> ounces 10 a.m. 

White of raw egg. sweetened 12 Noon 

Milk with peptogenic 2 p. m. 

Milk with peptogenic 6 P. m. 

Malt extract was discontinued every other week and an emulsion of codliver-oil 
ordered; 25 per cent, of oil was given. Each teaspoonful of the emulsion contained 
2 grains each of glycerophosphate of lime and glycerophosphate of soda. 

10 



146 INFANT FEEDING. 

May 14th: We discontinued giving peptogenic and simply gave the baby raw 
milk wanned immediately before feeding. The milk was thickened by giving 
zwieback and bread-crumbs. I also ordered steak-juice, fed several teaspoonfuls at 
noon with some bread-crumbs or cracker-dust, and roast-beef juice. Also ordered 
egg-crackers, bread and butter, and soup made with mashed peas in which meat was 
boiled. 

June 1st: Somatose V» teaspoonful to be stirred with milk or soup; repeat 
the dose three times a day. Also ordered raw apple-pulp sweetened with sugar. 

June 20th: Discontinued raw white of egg, and gave half of soft-boiled egg, 
half of yolk and half of white, followed by bottle of milk at 10 a.m. 

Child now weighs 19 V 2 pounds. 

Treatment discontinued; child went to the sea-shore. I did not see the child 
until middle of September, three months later. Has had summer complaint; food 
changed; different milk used in country evidently the cause. Child now weighs 
18 Va pounds. This child received pea-soup, cocoa, zwieback, and Nestle's food. I 
ordered: — 

Farina boiled in milk. 

Rice boiled in milk. 

Use one-half milk and one-half water. 

Boil one hour or longer. 

Also some barley-soup, afternoon cocoa, or milk, in the following manner: — 

Milk 4 ounces 

Water 4 ounces 

Granulated sugar 1 teaspoonful 

Lime-water 1 teaspoonful 



Feed at 6 A.M. 



Feed at 10 a.m., same as above, also farina or rice boiled in milk. 
Feed at 12 noon, soup made from chicken or beef thickened with barley. 



Feed at 2.30 p.m. - 



Milk 6 ounces 

Chocolate or 

Cocoa 2 teaspoonfuls 

Granulated sugar 2 teaspoonfuls 

Water 2 ounces 



Avoid all lumps in chocolate by rubbing up with hot water and gradually 
adding the milk. Heat over small flame and stir well. 

Feed at 6.30 p.m., milk thickened with egg-cracker or zwieback. 

This food was well assimilated, and then the following was added: Sliced apple 
in the morning; pudding made from broken zwieback, some milk, and yolk of egg. 

September 30th: Shredded wheat, oatmeal, or farina with milk, was allowed 
in addition to the afternoon cocoa or chocolate feeding above ordered. At noon 
chicken bouillon or soup, to which yolk of raw egg, well beaten, was allowed. 

In October we gave raw scraped steak on a soda-biscuit. Also ordered fresh 
vegetables, stewed or mashed peas, some spinach and cauliflower, and baked potato 
with butter. 

Bone-marrow, 1 teaspoonful three times a day, was ordered. 

The child made excellent progress. Teeth appeared, and the child is strong, 
well, and able to walk; no physical defect is visible; mentally the child is normal, 
and, indeed, to all appearances it is now a normal child. 



Formula I 



[LLUSTRATIVE BOTTLE-FEEDING. 147 

Ca^c III. — Dyspeptic Infant. Requiring Careful Bottle-feeding, now Perfectly 
Well Baby Douglas C. M., child of a physician, was born May 29, 1901. Weighed 
at birth !) pounds. Was breast-fed about two months. Owing to swollen breasts, 
the milk suddenly ceased. The child was weaned. Weight, 12 pounds. Stools 
normal at time of weaning. Hand-feeding with equal parts of milk and water was 
tried. As this was not well borne. Mellin's food was given. 

When first seen by me the infant had frequent attacks of vomiting; greenish 
stools, containing curds and mucus. Cries with colicky pains. Has constant in- 
testinal fermentation. 

Infant at 4 months, while suffering with colic, was given: — 

Pure milk 14 ounces 

Barley water l 20 ounces 

Granulated sugar 4 teaspoonfuls 

Lime-water '. 7 teaspoonfuls 

Mix the above and divide into seven clean bottles. Place in a refrigerator until 
required. At feeding-time empty contents of a bottle into a saucepan and allow the 
food to come to a boil, then immediately remove from heat. When cooled to feeding 
temperature, give it to the baby. Usual temperature is about 100° F., or blood-heat. 

In addition to the above food prune-water, made in the following manner, was 
ordered for thirst: — 

Fleshy prunes 1 dozen 

Granulated sugar 3 teaspoonfuls 

Water 2 pints 

Mix together and boil for thirty minutes. Strain; feed when cold. Three to 
C teaspoonfuls can be given at one time. 

Fresh orange-juice, 3 teaspoonfuls one hour before milk-feeding, once a day. 
When seen a few days later it was found that the child had had, during the 
day, five greenish-yellow stools, containing cheesy curds. 

Ordered oleum ricini, 1 teaspoonful at 10 a.m. 

Feed at 11.30 A.M. 

Feed at 2.30 p.m. 

Feed at 5.30 p.m. 

Feed at 8.30 p.m. 

If looseness continues, leave out sugar and substitute saccharin, V 2 grain to 
each bottle. 

Following: dav ordered: — 



> Formula II 



Milk 20 ounces 

Barley-water 14 ounces 

Sugar 4 teaspoonfuls 

Lime-water 7 teaspoonfuls 

Mix the above and divide into seven bottles. Scald each bottle before feeding. 



1 Barley-water is made by adding 1 heaped tablespoonful of prepared barley to 
1 quart of water. Boil half an hour, and strain through cheese-cloth. Add enough 
hot water to yield a quart. 



148 INFANT FEEDING. 

Infant cried and still seemed hungry after feeding, and the food was in- 
creased : — 



>. Font Aila III 



Whole milk 14 ounces 

Gravity cream 7 ounces 

Sterile water 20 ounces 

Cane sugar 5 teaspoonfuls 

Mix the raw milk and cream in a clean bottle and add the water and sugar. 
Divide into seven bottles and keep in a refrigerator until feeding-time. Keep bottles 
well stoppered with absorbent cotton. Warm the bottles in hot water at feeding- 
time. Feed every three hours. 

The following day the child had no stool from 2 A-ll to 10 a.m. It seems 
better satisfied after the bottle, and takes food greedily. 



Food changed to: — 

Whole milk 20 ounces 

Barlev-water 14 ounces 



1 



„ Formula IV 
Sugar 4 ounces 

Lime-water 7 teaspoonfuls 

Divide into seven feedings. Feed every three hours. 

As the above formula agreed. I ordered: — 

Whole milk 21 ounces ^ 

Barley-water 14 ounces L Formula V 

Sugar 4 teaspoonfuls 

Scald the milk and divide into seven feedings. Feed ever} two and three- 
fourths or three hours. 

Gained one pound during the week: has yellowish stools after each feeding; 
no vomiting: cries after feeding: appears dissatisfied. 

Changed feeding to: — 

Whole milk 30 ounces "\ 

Barley-water 12 ounces L Formula VI 

Saccharin 3 Va grains 

Divide into seven feedings. Scald the raw milk with hot barley-water: then 
put in ice-chest until feeding-time. Boil two minutes in saucepan before feeding. 

Stool after each feeding, yellow, normal consistency, alkaline reaction. Child 
does not sleep well: seems hungry. Food changed to: — 

Whole milk 30 oun: - "^ 

Barley-jelly l 12 oun - L Formula VII. 

Saccharin 3 Va grains 

Add 1 teaspoonful of cream to each feeding: discontinue if vomiting or if 
cheesy curds appear in stools. Scald milk as before. Feed every three hours. 

Child still appears hungry after feeding. Stools less frequent. Xo vomiting. 
Has small, rose-colored spots on legs and face. Weight. 13 pounds. 



- To make barley- jelly take 2 heaping tablespoonfuls of barley to 12 ounces of 
water, boil down, and again add enough water to make 12 ounces. 



ILLl STRATI LE-FEKD1 

Fowling changed U> — 

ounces * 

Formula VIII 



ounces 



Cream _ ounces 

i ide into ?even bottles and feed every three ho*; - 

If food does not agree add 1 teaspoonful of Fairehild's peptogenie milk-powder 
to each bottle and heat for three minutes before feeding. 

■:'.■'■■'.- .-—:' •:.■:'. : '-- _ _' --'■ . 

Child appears very bright. Has yellowish stools, no colic; abdomen not dis- 
tended. Xo evidence oi vomiting. Sleeps well at night. 

------ _ - — 

Milk - I 

Cream 4 ounces Formula IX 

I ::::l:z-: 1 -"..-; : " ---•::- 

and heat as before. Divide into seven bottles. 

7 r:\ ■'.>:■- >":. :.:;-! " ..-.'. ::■■:- ;• : - : r" .:. :.- : ".'::. "::■::". :z i ~ :,z 
for five hours, then dry in the oven, break open, reject the rind, and grate into 
powder. 

Child did not digest the dextrinizrd-wheat feeding. Changed to pure milk. 

L~:.:~.l z..- •;,■:-' :::-r :_:.•: : •: : ■.::'. : - 



To relieve eezematous excoriation on buttocks, ordered :- 




B. Calamin 


3.0 


Zinc oxide alb. 


1 


Lanolin or cold cream 


'-'_'■ 


Apply t. i. <L 





Child does not sleep well at night. Ordered milk steamed in double boiler 
for twenty-five minute*. Child cried very much during the last few days; had thin, 

- 

" - . -- — 
R Acid. HC1 dilu- 
tee of pepsin 60.0 
5 - 7 i spoonful three times a day before feeding. 

Owing to an eczema on the buttocks after applying the salve, ordered equal 
parts of pulverized zinc oxide and talcum dusted over salve on buttocks. 

For the loose bowels the rectum and colon irrigated with % pint of chamomile 
tea, to which was added 10 grains of tannic acid. Temperature of irrigation, about 

105 * F. 

' -- -■ :: -'-.. '- '.-:■. -:•:•::::-_! ::.: ::.. !".;.- 

Changed feeding to: — 

Milk . 4 , 

Barley-- : : ; _. ounces Formula X 

Arrowroot 1 heaped teaspoonful \ 

BoiL and feed pr three or three and one-half hour>. alternating with thick- 

ened rice-soup or riee-wa: 6 ounces at one feeding. Baby did very well on 

this diet, assimilated the food, and gained in weight. Had one or two yellowish. 



150 



IX FAX T FEEDING. 



well-digested stools daily. After this improvement I ordered soups and white of 

egg- 

The child weighed, at six months, IS pound-. The child is perfectly well, walks 
and talks, and is now in his second year, with normal dentition. 

Materna Home Modifier. — -This is a glass apparatus for the modification 
of cows' milk at home, and consists of a glass vessel with pouring-lip, shaped 
like a graduate, holding 10 ounces. The outer surface is divided by vertical 
lines into seven panels ; one panel shows the ordinary ounce graduation : 
the six others show six different formulae, so arranged as to be suitable for 
the entire first year's feeding. The accompanying diagram is a more or less 
accurate reproduction of the arrangement of these panels. 




Fig. 44. — Materna Home Modifier. 



It is possible to obtain other percentages than those shown on the 
panels, by mixing what is called for by two adjacent formula? : as. for in- 
stance, equal quantities made according to Formulae 1 and 2 combined will 
give: fat. "2 % per cent.; proteids. 0.7 per cent.: sugar. 6 per cent. 

As may readily be seen, all the formulae call for the same ingredients, 
excepting the sixth, which, instead of water, requires barley gruel, and 
granulated sugar in place of milk-sugar. 

The method of using the apparatus is extremely simple. Haviug de- 
cided upon the formula to be used, that panel is to be observed to the ex- 
clusion of all the others. The respective ingredients are then poured into 
the vessel, to the line below the designated substance. Thus, milk-sugar is 
put in first (or. in its absence, granulated: and the line with the cross 
shows to what point the latter should be used), then the water, lime-water, 



HO.MK MODIFICATION. 



151 



cream, and milk in the order shown. The whole is then stirred, and the 
result will be a milk whose formula is' at the top of the panel. The milk 
used with the apparatus should be good average milk. The cream should ho 
the lighl centrifugal cream as obtained in bottled milk- (16-20 per cent.). 
The water should be hot, to dissolve the sugar. The barley gruel should be 
prepared in the usual way with Robinson's or ordinary barley. 

According to the age and size of the child, the vessel must be filled 
once, twice, or three times to obtain the quantity requisite for the twenty- 



1. 

8d-14th Day. 

Fat 2<<. 

Proteids, 0.6£ 

Sugar, 6£ 


2. 

2d -6th Week. 

Fat, 2%«. 

Proteids, 0.8£ 

Sugar, 6jf. 


3. 

6-llth Week. 

Fat, 30. 

Proteids, 1£ 

Sugar, 6*. 


4. 

11 wk.-5 mo. 

Fat, 3%*. 

Proteids, 1%#. 

Sugar, 7& 


5. 

5th-9th month. 

Fat, 4^. 

Proteids, 2£ 

Sugar, 7jt 


6. 

9th-12th month. 

Fat, V/rf.. 

Proteids, V/A 

Sugar, 3J^C 


Milk 


Milk 


Milk 


Milk 


Milk 


Milk 


Cream 


Cream 


Cream 


Cream 


Cream 








Lime-water 


Lime-water 




Lime-water 








Water 


Water 






Water 


Lime-water 






Milk-sugar 






Lime-water 






Milk-sugar 






Water 






Water 


Cream 




Milk-sugar 


— 




Milk-sugar 


Barley-gruel 


Milk-sugar 








Gr. sugar 






















1 





four hours' feeding. The pouring into bottles and sterilization are then 
done as usual. Full directions, including a schedule for the twenty-four 
hours' feeding at the various periods of the child's growth, accompany the 
apparatus, which is simple, accurate, and economical, making properly 
modified milk of practical value obtainable in places where it has hitherto 
been impossible to get it. 

The materna is adapted for home use only when the physician notes 
results. To intrust an apparatus of this kind into the hands of a mother 
or nurse not conversant with the difference in the percentage of fat contained 
in cream is not only wrong, but will prove disastrous to the infant so fed 
before many weeks are over. The author recently saw a case of dyspepsia 



152 



INFANT FEEDING. 



brought about by feeding in this careless manner. On the other hand, the 
apparatus will serve as a guide to those physicians whose training in per- 
centage-feeding requires occasional assistance. 

A very practical "milk modifying gauge" devised by Mitchell has been 
placed on the market. It can be procured from the National Drug Com- 
pany of Philadelphia. It is designed to aid those unfamiliar with home 
modification, and is especially valuable to those distant from large cities 
with laboratories. 



\ t* 







t-X rAT HIIKSUCW PBOTCloa! 














Z' w« 


2a> 














7 
7 


&> 


s 






tv 










3-4 MO 










,i» MO 














4 




S 1 








a. 


*?« 1 





Fig.3. 



Fig. 45. — Mitchell's Milk Modifying Gauge. 



Table No. 29. 
Diet for a Child from One Year to Fifteen Months. 1 



10 a.m. 
12.30 p.m. 



Orange juice, 

Apple sauce, or 

Prune jelly. 

Milk, 8 ounces, with zwie- 
back or crack ers. 

Milk, 8 ounces. 

Beef or chicken soup, thick- 
ened with toast crumbs, or 



12.30 p.m. 



5 P.M. 

G.30 p.m. 



Expressed steak juice or 
beef blood, with toast 
crumbs. 

Milk, 8 ounces, with soda 
biscuit 

Apple sauce. 

Milk, 8 ounces. 



1 In the chapter on "Weaning," I have already described in detail another method 
Of substitute feeding for a child about 1 year old. 



DIET KOU A CHILI) FROM ONE AM) ONE-HALF TO TEN YFAKS. i;>;; 

Table No. 30. 
Diet fob a Child from Eighteen Months to Three Years. 

6.30 a.m. Orange juice. 2p.m. Clear broth, with yolk of 

Apple sauce, or egg, or one or more ounces 

Prune jelly. of expressed beef blood. 

7.30 a.m. Warm milk, 8 ounces; Oyster or clam broth. 

Mellin's Food, 1 teaspoon, or Joint of chicken, 

Eskay's Food, 1 teaspoon; Broiled halibut, 

Zwieback or cracker, with Raw scraped steak, 

butter. Chicken jelly, or 

11 a.m. Farina, Calf's-foot jelly (without 

Hominy, wine flavor). 

Cream of wheat, Baked potato, with butter; 

Oatmeal, or Spinach, or 

Grape-nut, scalded with hot Carrots. 

milk; in addition, a cup of 6 p.m. Crust of bread or zwieback. 

Warm milk, 6 ounces. Warm milk, with white of 

2 p.m. A soup, a meat, a vegetable, egg; or 

and a cracker. Cocoa. 

Beef or chicken soup, thick- Junket, custard, corn starch, 

ened with split peas, sago, tapioca, or farina pudding, 

rice, or farina. a few teaspoonfuls. 
Drink of water. 

Diet for a Child from Three to Ten YeafvS. 

A child of 3 years, excepting in rare instances, should not be fed oftener 
than three times a day. The best time for feeding is : morning meal, 7 to 
8 a.m.; noon meal, 12 to 1 p.m., and evening meal, 5.30 to G.30 p.m. 

In rare instances fruit or a cup of milk may be allowed between the 
noon and evening meal. 1 In the majority of cases five hours are required 
to fully digest the food given. 

The morning meal should consist of a fruit, a small dish of cereal with 
cream, a cup of milk, and a piece of toast or crackers. 

The noon meal should consist of a plate of soup, a small portion of meat, 
a small potato, a vegetable, bread, or crackers, or stale sponge cake, water. 

The evening meal should consist of an egg or pudding, a cup of cocoa 
or milk, crackers or bread with butter or honey. 

It is safer to give a light meal in the evening rather than load the 
stomach with heavy food. The American custom of eating dinner at night 
should not be applied to children. 

That milk is very absorptive is well recognized. It is a bad precedent 
to store it away in refrigerators, unless it is placed in sealed jars, apart 
from foods which exude odor. 



1 Horlick's Food Co. make a malted milk lunch tablet, coated with chocolate, 
that is nutritious and digestible. They are especially indicated when small meals 
should be given. 



154 



IXFAXT FEEDING. 



Selection can be made from the following dietary : — 

Table No. 31. 



MORNING MEAL. 



Fruit- 
Raw, stewed, or baked apple. 

Grapes. 

Grapefruit. 

Oranges. 

Cherries. 

Peaches. 

Banana. 

Stewed prunes. 
Cereals — 

Hominy. 

Oatmeal. 

Farina. 

Force, or 

Wheat Flake Celery Food. 



Cereals — 

Shredded wheat. 

Cream of wheat. 

Wheaten grit. 

Arrow root. 

Cerealine. 

Yellow indian meal. 

White indian meal. 

Wheat flakes. 
Buttered toast. 
Albert cakes. 
Zweiback. 

Vienna bread and butter. 
Stale sponge cake. 
Lady fingers. 



NOON MEAL. 



Meat or chicken soup, thickened with 
lentils, peas, split peas, sago, farina, 
rice, or egg. 

Meat- 
Broiled chop, steak, or fish. 
Chicken. 
Stewed tripe. 
Sweet-bread. 
Raw scraped beef. 
Roast beef. 



Meat- 
Lamb. 
Bone marrow. 

Baked or mashed potatoes, spinach, peas, 
beans, tomatoes, cauliflower, carrots, 
asparagus, rhubarb, cranberries, or 
celery. 

Apple cider, buttermilk, kumyss, seltzer, 
lemonade, or yery weak tea. 



EVENING MEAL. 



Crackers and milk. 

Custard. 

Cornstarch pudding. 

Corn muffins. 

Farina pudding. 

Milk toast. 

Tapioca pudding. 

Chicken jelly without wine. 



Calf s-foot jelly without wine. 

Junket. 

Oysters. 

Boiled, scrambled, or poached eggs. 

Cream of barley. 

Cream of rice. 

Cocoa and milk. 

Toast or crackers. 



Articles of Food Which Should be Forbidden Until After the Tenth to 
Twelfth Year. — Fruit: All dried fruits (with the exception of prunes), 
preseryed fruits, fruits out of season, over-ripe fruits or under-ripe fruits. 

Meats. — Pork, ham, bacon, sausages, kidneys, duck, and goose. 

Vegetables. — Cabbage, onions, radishes, cucumbers, turnips, and egg 
plant. 

Drinks. — Coffee, tea, and ice cream soda. 

All candies, cakes, nuts, pies, and salads must be forbidden. 



dextrinized food. 155 

Feeding of Delicate ob Sick Children. 

[nfanta having weak digestion or dyspeptic infants require modification 
of the caseia in the milk. In such cases the milk should be prepared or 
predigested. Sometimes dextrinizicg the food will eo thoroughly break up 
the curd of the milk and render it so finely flocculent that it will be much 
better adapted for a subnormal stomach. 

Method of Dextrinizing 1 . — Prepare the wfieat, barley, oatmeal, or rice 
flour by adding a tablespoon ful of the same to a pint of water, adding a 
pinch of salt, and boiling the same for from fifteen minutes to one hour. 
This will make a gelatinous solution, and hence the name of barley jelly, 
rice jelly, oatmeal jelly, or wheat jelly. We allow this jelly to cool, and 
when cool enough to be tasted we can add a diastase, such as cereo; or taka- 
diastase, made by Parke, Davis & Co. ; or the Forbes diastase. When a 
small quantity of this diastase is added to the jellies above mentioned, they 
lose their thickness, and become very thin. They can easily be strained 
through cheese cloth, and some water added to make up for the loss by 
evaporation during the boiling. This jelly, or gruel, as it is sometimes 
called, made from either barley, rice, wheat, or oatmeal, is to be used with 
the milk after the diastase is added. In certain diseases where milk is not 
well borne, such as dyspepsia (dyspeptic vomiting), or in summer complaint, 
where the giving of milk is prohibited, feeding with dextrinized gruels for 
several days will be found not only very useful, but very healthful. In 
making this dextrinized gruel, small particles will be seen floating, which 
settle out upon standing. These particles consist of the cell walls and the 
proteids of the cereal, and cut the curds of the milk into fine pieces, 
when the curds begin to shrink under the combined action of rennet and 
acid. In using this diastase we aim at breaking up the tough curd in cows' 
milk by purely mechanical means. 

Homemade Diastase for Dextrinizing Food. — Henry D. Chapin 1 de- 
scribes a simple decoction of diastase made as follows : "A tablespoonful 
of malted barley grains is put into a cup, and enough cold water added to 
cover it, usually two tablespoonfuls, as the malt quickly absorbs some of 
the water. This is prepared in the evening and placed in the refrigerator 
over night. In the morning the water, looking like thin tea, is removed 
with a spoon or strained off, and is ready for use. About a tablespoonful of 
this solution can be thus secured, and is very active in diastase. It is suffi- 
cient to dextrinize a pint of gruel in ten to fifteen minutes." 

During the summer, in the critical cases of summer complaint in 
which subnormal digestion existed, the author has seen very good results 
follow the administration of anv and all of the malt extracts now in our 
market. Frequently the administration of a half-teaspoonful of malt extract 



Journal of the American Medical Association. Julv 14. 1000. 



15G INFANT FEEDING. 

to an infant immediately before feeding was not only relished by the infant 
on account of the pleasant taste of the malt, but certainly aided in the 
assimilation of the food. Rarely was more than three teaspoonfuls of malt 
ordered during twenty-four hours. Such preparations as maltine give very 
good results. The malt extract has a very pleasant flavor and is Avell borne. 

Frequently, when expense proved an important item, sufficient dex- 
trinization of foods could be procured with these malt preparations above 
cited. 

It is claimed by some that most malt preparations deteriorate on stand- 
ing or if exposed too long; this is certainly untrue. 

Substitute Feedixg. 

Gastric disturbances such as vomiting or diarrhoea contraindicate the 
use of milk. When colic follows the use of milk we are frequently com- 
pelled to discard milk until such acute symptoms subside. If a child has 
large or small cheesy curds in the stool and does not gain in weight, then 
the food is improper. 

During acute infectious diseases, such as scarlet fever, diphtheria, or 
typhoid fever, we are compelled to reduce the proteid element owing to its 
lack of assimilation. 

The food indicated is one that is very nutritious and easily digested, 
such as whey or sweet almond milk (see dietary). If the child is 1 year 
or older, soup thickened with split peas or beans, a chicken, mutton, or 
veal broth may be fed in three or four hourly intervals. Soup thickened 
with toasted bread crumbs may also be given. 

For a Baby Under One Year. — When the symptoms previously described 
are present in an infant and milk must be stopped, trophonine, made by 
Eeed & Carnrick, in teaspoonful doses every hour, is a valuable substitute. 
Whey is also indicated. 

In acute milk infection and summer complaint, during my summer 
service at the Riverside Hospital, I have seen children retain trophonine 
when food containing the slightest trace of milk was rejected. 

I have frequently used : — 

Nestle's Food 2 teaspoonfuls 

Water 8 ounces 

Warm in saucepan until it boils. Feed 3, 4, or 5 ounces every few hours. 

Feedixg-bottles. 

A proper feeding-bottle is one that has no corners or angles on the 
inner surface. The bottom should be rounded so that every part of the 
same can be properly cleaned. Bottles that have corners and grooves will 
harbor bacteria. 



FEEDING-BOTTLES. 



157 



My preference lias always been for two kinds of bottles: 1. Those 
holding I ounces and graduated on one side in both ounces and tablespoons; 
this saves much time and trouble. 2. Bottles holding 8 ounces and divided 
off into 16 tablespoonfuls or S equal ounces. 

Exactness of Ounces. — It may not be out of place to ask each physician 
to insist on having the graduated ounces on an infant's feeding-bottle meas- 
ured with an accurate graduate, obtainable at every drug store. In many 
instances the author noted feeding-bottles wherein the ounces indicated 
were very unequal, and one particular bottle, graduated to 8 ounces, held 
12 ounces. 





Fig. 46. Fig. 47. 

Fig. 46. — Author's Choice of Feeding-bottle. 

Fig. 47. — Bottle Warmer. A convenient bottle warmer, adapted for 
keeping the night feeding warm, is here illustrated. It is made by the 
Arnold Sterilizer Co. It is also useful when traveling. 



Long Rubber Tubes. — Most prominent pediatrists agree that the long 
rubber tubes are a convenient place for harboring micro-organisms, and they 
have been universally condemned. 

Care of the Bottle. — Every bottle should be thoroughly cleaned with 
a brush and a solution of baking soda and water, a teaspoon of soda to a 
pint of water. The bottles must then be thoroughly rinsed with clear water. 
If milk has fermented or if some residue adheres to the bottle and the same 
cannot be properly cleaned, then boiling the bottles will be necessary. In 
general and for daily use the bottle need not be boiled every day. 

Proper Time for Cleaning Bottles. — The best time to clean a bottle is 
immediately after the baby has been fed ; this prevents the food souring 
in the bottle, and it is very easily cleaned. 

The bottle brush has a long handle and bristles for cleansing the bottles. 
This brush should be used before the bottles are put into the soda solution. 



158 INFANT FEEDING. 

It is understood that the brush can itself harbor bacteria and particles of 
milk removed while cleansing. It is therefore understood that the brush 
must be thoroughly boiled in a soda solution after each use. 




Fig. 48.— Bottle-brush. 

Choice of a nipple is another important matter. My preference has 
always been for a black-rubber nipple, and it is a very wise point to use a 
nipple no longer than one week ; in other words, old, worn nipples are useless 
for the proper management of infant-feeding. Black rubber is softer than 
white rubber; most white rubber is supposed to contain lead; hence a 
decided reason for not using it. 

Nipples Recommended. — One of the best nipples made is the so-ca'led 
anticolic nipple. This nipple has a ball-shaped top, which enables a baby 
to take a firm hold; it has three small holes, which give an easy flow of 
milk, and regulate a slow meal. Nipples having very large openings, which 
will permit a baby to finish a 6 or 8-ounce bottle of food in five or six min- 
utes, are useless, and this gulping of food is really the cause, or one of the 
causes, of infantile colic. 







Fig. 49. — Anticolic Nipple. 

I have used another nipple, but it is much harder to clean, and unless 
all precautions for sterilization are carefully noted it should not be used; 
yet, in the hands of the intelligent or where we have a trained nurse, it can 
be safely recommended. It is called the "Mizpah." This nipple has also 
a very small puncture, so that the baby gets the food slowly. 

The "swan-bill" nipple and the long French nipp 1 ^ I also like. I have 
noted just as good results as with the above-mentioned kinds. 



STERILIZATION OF MILK. 159 

Ventilated Nipple. — A nipple very highly spoken of is the ventilated 
nipple made by Ware, of Philadelphia, which has a small opening or valve 
en the side. and. as the milk is drawn in from the bottle, it permits air to 
inter, thus preventing a vacuum from being formed. It is also supposed to 
he non-eollapsihle, and is highly recommended by those who have used it. 
The only objection — already offered — is that all nipples must not only be 
practical for use, hut must be capable of thorough sterilization. 

Cleaning the Nipples.— The prevention of stomatitis and mouth affec- 
tions depend upon proper hygiene of the nipple. It does not require much 
time or trouble to remove the nipple from a bottle and throw it into boiling 
water immediately after using. Boracic aeid or common salt may be added 
to the boiling water. A nipple thus treated is properly sterile. 

The nipple sterilizer (see Fig. 50) is a very convenient little arrange- 
ment made by Ware, of Philadelphia. It serves the purpose admirably for 
the sterilization of nipples. 




Fig. 50. — Nipple-sterilizer. 



Sterilization of Milk. 



When Soxhlet first announced the method, of sterilization, he awoke the 
profession to the realization of the dangers lurking in crude cows' milk. 
His aim w r as to destroy pathogenic bacteria, and give the infant a milk 
which did not contain living bacteria. 

In order to sterilize milk accordingly to Soxhlet, we must heat milk 
to a temperature of 212° F. and continue this steaming for thirty minutes. 
We know that heating milk produces many changes, some of which are 
not thoroughly understood. Other changes have been positively proven. 

Changes in Milk Caused by Sterilization. — In some experiments made 
by Dr. E. M. Hiesland and published by Dr. B. C. Hirst, 1 it was found that 
by sterilization : — 

1. The albumin is coagulated. 

2. Casein is less readily precipitated by rennet than in normal milk. 

3. Fat is freed to a slight extent; fat not freed has a 'lessened tend- 
ency to coalesce. 



i Medical Xews, January 31, 1891. 



160 INFANT FEEDING. 

4. Sugar undergoes some change, as shown by its lessened dextrorota- 
tory power. 

The considerations suggested by the foregoing facts are : — 

1. The coagulation of milk-albumin by sterilization may render the 
milk more difficult of digestion. 

2. Sterilization interferes with the coagulability of milk by rennet, 
and presumably, therefore, with its digestibility by the gastric juice. 

3. Free fat, as found in sterilized milk, is probably not readily assimi- 
lated in infant food. The fat not free, being inclosed in a less easily 
destructible envelope, is probably slow of digestion. 1 

On the question of sterilized milk the weight of evidence seems to show 
that the process, while preventing undue fermentation, so changes certain of 
the natural ferments and some of the fats that the milk is less easily 
digested and less nutritious. 2 

The sterilization of milk is advocated chiefly to destroy pathogenic 
bacteria. The profession has been educated to the belief that we must kill 
all living micro-organisms in food. 

When the method was first advocated, the profession adopted it in all 
parts of the world; so that thousands of babies have been brought up on 
sterilized milk. Within the last few years sentiment has changed. Steril- 
ization accomplishes the destruction of pathogenic bacteria, but it also pos- 
sesses certain disadvantages. 

The spores of pathogenic bacteria cannot be destroyed by the ordinary 
process of sterilization. 

To properly sterilize milk it is necessary to subject it to the process of 
tyndallization. This will render milk germ-free. This latter process con- 
sists of subjecting the milk to the process of sterilization for at least twenty 
to thirty minutes on three successive days. For practical purposes it is 
useless. 

The chemical changes produced in milk by the process of sterilization 
are as follows : The lactalbumin coagulates at a temperature of 160° F. 
(70° C). Thus the temperature being 212° F. renders this ingredient 
decidedly different from what it appears in its raw state; the casein is 
rendered less coagulable by rennet and appears to be acted upon more slowly 
both by pepsin and trypsin; the organic phosphorus is changed into an 
organic phosphate ; citric acid is partially precipitated as calcium citrate, 
and some lime salts, which are usually soluble, are converted into insoluble 
compounds. 

Certain changes also occur in the fat. Moreover, certain natural fer- 
ments in fresh milk, believed to be of value in digestion, are destroyed by 
heat. 



1 Medical Record, February 28, 1891. 

2 North American Practitioner, June, 1892, from the "Year-book of Treatment' 
( Lea Brothers & Co ) . 



STERILIZED BULK. 1G1 

Many of these changes are but imperfectly understood, and some of 

them are doubtless without any injurious effeel upon nutrition. There is, 
however, one important clinical reason for believing that the nutritive prop- 
erties of milk are impaired by heating- to 312° P., viz.. the occurrence of 
scurvy in infants who are fed upon such milk for a long time (Holt). 

We know that a great many children fed on sterilized milk develop 
scurvy. The same is true of children fed on boiled milk. The reason is, 
Kundlett so ably says: "Changes take place not in the albumin, fat, nor 
sugar, but in the albuminate of iron, phosphorus, and possibly in the fluorine 
vital changes take place. These albuminoids are certainly in the milk, de- 
rived as it is from tissues that contain them, and are present in a vitalized 
form as proteids.'' On boiling, the change taking place is simply due to 
the coagulation of the globulin, or proteid molecule, which splits away from 
the inorganic molecule, and thus renders it, as to the iron and fluorine, 
unahsorbable and, as to the phosphatic molecule, unassimilable. This is 
the change that is so vital, and this only takes place w r hen milk is boiled. 

It is evident that children require phosphatic and ferric proteids in 
a living form, which are only contained in raw milk. 

Cheadle says that phosphate of lime is necessary to every tissue; no 
cell growth can go on without earthy phosphates; even the lowest form of 
life — such as fungi and bacteria — cannot grow if deprived of them. These 
salts of lime and magnesia are especially called for in the development of 
the bony structures. 

Avoidance of Scurvy. — Since clinical experience has demonstrated that 
the prolonged use of sterilized milk and boiled milk will produce scurvy. 
and that improvement is immediately noted when raw T milk is given, or 
raw muscle juice (beef-juice) or raw white of egg, added to fresh fruit 
juices, does it not seem more plausible to commence feeding at once with 
raw milk rather than after scurvy or rickets is developed? 

There is a certain deadness, or, to put it differently, absence of fresh- 
ness, that is lacking in milk that has been boiled or sterilized, just as it is 
the absence of fresh meats and green vegetables which is known to cause 
scurvy in the adult. 

In my own practice I have so frequently been disappointed in the use 
of sterilized milk that within the last few years I have entirely discarded 
it- use. 

The Disadvantages of Sterilized Milk From a Clinical Standpoint. — 
The first effect of using sterilized milk is that the child will he con- 
stipated. It is for this reason decidedly objectionable. It is wise to re- 
member that one of the earliest symptoms of rickets is constipation. We 
have known that the prolonged use of sterilized milk results in rickets. 
The symptom of constipation should therefore be looked upon not as a 
temporary, but as a permanent, damage to the body. Therefore, it should 



162 INFANT FEEDING. 

not be neglected. Appropriate dietetic treatment can easily modify con- 
stipation. Clinicians all agree that the prolonged use of sterilized milk 
cannot be advocated. There may be individual children who thrive on 
prolonged use of sterilized milk, and J dare say oir any form of feeding. 
We are dealing, however, with average children, and these all show a cer- 
tain train of symptoms. 

Constipation of the most stubborn kind will be encountered in all 
children fed on sterilized milk. This condition exists regardless of the 
season of the year. Children do not thrive as well on sterilized milk as they 
do on milk subjected to a much lower degree of temperature. Sterilized 
milk is rendered less digestible than it is in its raw state. 

Freeman 1 says that the modifications produced in milk heated to 212° 
F. consist in the starch-liquefying ferment being destroyed, the casein 
being rendered less coagulable and therefore being acted upon slowly and 
imperfectly by pepsin and pancreatine, and the milk-sugar being destroyed. 

Fayel, 2 discussing boiled milk, says that it is more indigestible, and 
in no respect safer than unboiled milk. The temperature at which it boils 
is insufficient to destroy microbes, and the milk is therefore not sterilized. 
Its density is increased by the boiling, above that suitable for infant diges- 
tion. 

Milk consists of a multitude of cells suspended in serum. The cells 
are fat cells which form the cream. The remaining cells are nucleated and 
of the nature of white corpuscles. The serum consists of water in which 
is dissolved milk-sugar and serum albumin, with various salts and chief 
of all casein. The cells, with the exception of fat corpuscles, are all living 
cells, and they retain their vitality for a considerable time after the milk 
is drawn from the mammary glands. 3 

There is reason for supposing that when fresh milk is ingested the 
living cells are at once absorbed without any process of digestion, and enter 
the blood-stream and are utilized in building up the tissues. The casein 
of the milk is digested in the usual way as other albuminoids by the gastric 
juice, and absorbed as peptone. There is also absorption of serum albumin 
by osmosis. The chemical result of boiling milk is to hill all the living cells 
and to coagulate all the albuminoid constituents. Milk after boiling is 
thicker than it was before. 

The physiological results are that all the constituents of the milk must 
be digested before it can be absorbed into the system; therefore, there is 
distinct loss of utility in the milk, because the living cells of fresh milk 
do not enter into the circulation direct as living protoplasm and build up 
the tissues direct, as they would do in fresh, unboiled milk. In practice it 



x Paper read at Academy of Medicine, New York, May 11, 1893. 

2 Medical Age, September 25, 1893. 

3 J. L. Kerr, British Medical Journal, December, 1895. 



STERILIZED MILK. li;;; 

will have been noticed by most medical practitioners thai there is a very 
distinctly appreciable lowered viiality in infants which are fed on boiled 
milk. The process of absorption is more delayed and the quantity of milk 
required is distinctly larger for the same amount of growth and nourish- 

menl of the child than is the case when fresh milk is used. 

\ aughan does not believe that milk is benefited by either sterilization 
or pasteurization, hut such procedure is necessary when market mill,- is used, 
because the latter is seldom or never obtained under aseptic precautions. 

Some people have an idea that it matters not hoiv filthy a coir's milk 
is, or how mam/ germs it may con lain, if it be pasteurized or sterilized it 
then becomes a fit food for children. This is not true, because, in the first 
place, even prolonged boiling does not lilt the spores of all bacteria; and, 
in the second place, the chemical poisons produced by certain germs are not 
altered by the temperature of boiling milk. 

After milk has been either sterilized or pasteurized it should be kept 
at a low temperature before being fed to the child. This should be regarded 
as a necessary procedure in the preparation of infant food. The fact that 
milk in which the colon germ has already grown abundantly cannot, by 
any process of sterilization or pasteurization, be rendered fit food for chil- 
dren should be emphasized. The toxin of the colon bacillus may he heated 
to 1S0° C. (356° F.) for half an hoar without having its poisonous prop- 
erties diminished. If clean mill- be obtained and healed at 1J/.0 F. to 150° 
F. and then for ten to fifteen minutes kept at a low temperature until fed 
to the child, it furnishes the best food which it is possible for us to obtain 
under ordinary circumstances. 

Sterilization of Milk at 212° F. for Thirty Minutes (Soxhlet Method). 
— Bottle-cleaning : Always cleanse the bottles thoroughly before using 
them if they are new bottles. It is a good plan to give them one good 
washing by adding a pinch of bicarbonate of soda to each bottle, boiling 
for at least five minutes in this soda water, and then boiling for at least a 
quarter of an hour in ordinary water. The bottles are then turned upside 
down to allow the water to drain off; I then insert a large stopper of non- 
absorbent cotton (sterilized non-absorbent cotton from a drug store is 
better than the white absorbent cotton). The neck of the bottle is stoppered 
at least three-quarters of an inch. 

Place the bottles previously filled with milk or the feeding mixture 
in the rack, and set the rack in the sterilizing chamber, and cover tightly 
with the lid and hood. 

Fill the reservoir (pan) two-thirds full of water and place the appa- 
ratus over a moderate fire for one hour. If the milk is just from the cow 
forty or fifty minutes are sufficient (twenty minutes for heating and twenty 
or thirty minutes for sterilization). 



164 



INFANT FEEDING. 



The sterilizer may be used on a gas stove (turned low), kerosene stove, 
or upon an ordinary cooking stove; if over the last named, the griddle 
should not be removed. You can tell by a bubbling sound that the steril- 
izer is working all right. If the water is not bubbling with regularity in- 
side, you need more heat. It must not be put on the fire without water in 
the reservoir and the water should never be allowed to get lower than one 
inch from the bottom. With proper attention as to the quantity of water 
in the reservoir no further care need be given to the apparatus or to the 
contents of the chamber, for the prescribed time. 

It is not necessary to place the bottles on ice after removing them from 
the sterilizer, but all bottles should be placed in a refrigerator until taken 
out for feeding, leaving in the cotton plugs until it is feeding time. The 




Fig. 51. — Arnold Steam Sterilizer. 

directions sent out with some sterilizers, that milk will keep for days im- 
plies that infants' milk may be prepared for several days at once. To this 
I decidedly object. A great many authors have pointed out cases of Barlow's 
disease due to milk which had been sterilized and not used for a long time. 
Before feeding the bottle is to be thoroughly warmed by putting it into a 
small measure or bottle-holder, and heating it with alcohol or gas to about 
the body temperature of 98° or 100° F. Immediately before using shake 
the bottle, so as to mix the cream and the milk, which invariably separates 
in a refrigerator; remove the cotton and draw on the nipple. 



Pasteurization. 

Heating milk to 75° C, as is done by many of the methods, does not 
sterilize, for the spores of the bacillus subtilis can withstand this temperature 
for several days. The spores will resist the temperature of 100° C. (212° 
F.) for six hours. Upon heating to 110° to 120° C. (230° to 248° E.) 



PASTE! RIZED MILK. 



Km 



the milk will be thoroughly sterilized, but Buch heating causes a browning 
of the milk, and the cream-cells are apt to be broken and the fat or butter 
will rise to the surface. 

Pasteurization with a temperature between 60° and 80° C. (140° to 

F.) destroys tubercle bacilli and. according to Van G-euns, destroys 

also the typhoid bacillus, the cholera bacillus, and the pneumococcus of 

Friedlander, and also most of the ordinary milk germs, and does not injure 

the milk. 

('. II. Stewart gives the following interesting result of the heating of 
milk at various temperatures, and its result on the albumin: — 

Table No. 32. 



Time of Heating. 


Soluble Albumin 
in Fresh Milk. 


Soluble Albumin 
in Heated Milk. 


10 minutes at 60° C. (140° F.) 

30 minutes at 60° C. (140° F.) 


Per Cent. 
0.423 
0.435 
0.395 
0.395 
0.422 
0.421 
0.380 
0.380 
0.375 
0.375 


Per Cent 
0.418 
0.427 


10 minutes at G5° C. (149° F.) 


0.362 


30 minutes at 05° C. (149° F.) 

10 minutes at 70° C. (158° F.) 

30 minutes at 70° C. ( 158° F. ) 

10 minutes at 75° C. (l«7°F.) 

30 minutes at 75° C. ( 167° F. ) 

10 minutes at 80° C. (176° F.) 


0.333 
0.269 
0.253 
0.070 
0.050 
none 


30 minutes at 80° C. (176° F.) 


none 







We can see that heating milk at 140° F. for ten minutes or for thirty 
minutes still leaves about the same proportion of soluble albumin as we 
find it in fresh milk. When milk is heated only ten minutes at 17 G° F. 
no soluble albumin remains, while in fresh milk about 0.37 5 is found. 

An interesting bacteriological report was made on pasteurized milk 
by a eommittee representing a medical society of Washington/ of which 
the following synopsis is well worth noting: — 

'"The number of bacteria per cubic centimeter in pasteurized milk has 
heen found, as a rule, to be less than 200. In some cases no bacteria could 
be detected. In four instances the number of bacteria per cubic centimeter 
increased to over 5000. A comparison with the number of bacteria in the 
sanitary milk on these same dates showed a very much larger number of 
germs than should have been present if proper precautions had been used. 
In 113 sample- of sanitary milk examined, the number of colonics per 
cubic- centimeter has in the majority of cases varied from 200 to 5000. 
Three samples showed over 50.000 colonies per cubic centimeter: 3 others 
over 2D.000 and less than 50,000 colonies per cubic centimeter; 1 over 
15,000 and less than 20,000 per cubic centimeter: 2 others over 10,000 
and less than 15,000: 2 others over 5000 and less than 10.000. 



Published in tin- National Medical Review, Washington, T). C. April, 1S99. 



1(36 INFANT FEEDING. 

"When we consider, however, that in the milk supply of our large 
cities the number of bacteria per cubic centimeter has been found to vary 
from 30,000 to 85,000,000, and has often been found as high as the number 
of bacteria in the sewage of several towns, namely, between 1,000,000 and 
4,000,000 per cubic centimeter, the value of the number of bacteria per 
cubic centimeter of milk, as indicating the care which has been used in 
collecting and handling the milk, is at once apparent. One of the German 
authorities on the subject of sanitary milk (Bitter) claims that the maxi- 
mum limit for milk that is fit for food is 50,000 germs per cubic centi- 
meter. On this basis, the milk from only thirteen out of thirty-two 
dairies, which has been examined in "Washington, would be fit for food." 

There is a slight taste or flavor which is noticeable when milk is 
heated to 158° F. for fifteen minutes. For practical purposes, however, 
milk heated to 1^0° F. serves very well and has no taste at all. Pasteurization 
of milk has been received by the profession with the same enthusiasm as 
was sterilized milk when it was first announced. The mistakes that have 
been made by forcing- infants to swallow milk sterilized at a temperature 
of 212° F. for thirty minutes are evident in so far as such children can 
show a devitalized condition into womanhood and manhood. Constipation 
and rickets are recognized as associate factors during sterilized milk feed- 
ing. The profession at large is rapidly departing from this improper and 
dangerous method of treating raw milk. 

What has been said of sterilized milk applies in a lesser degree to 
pasteurized milk. I have frequently found cases of infants fed on 
pasteurized milk that showed the same symptoms, though in a milder 
degree, than what we know to be true of sterilized milk feeding. 

When my advice is sought regarding the utility of pasteurizing milk, 
I always say: You should pasteurize your milk at a temperature of 140° to 
150° F., for ten minutes, if you do not know the source of your milk supply. 
In New York certified milk or guaranteed milk is procured, and it is un- 
necessary to change the chemical character of the milk by prolonged heating. 
With certified milk it is simply necessary to use sterile utensils and warm 
the food to a little higher than feeding temperature. 

The Caloric Method of Ixfaxt Feedixg. 1 
A calorie is the amount of heat necessary to raise the temperature of 
one kilo of water one degree (Celsius), in other words it is the deter- 
mination of the heat-energy expressed by a given number of calories as 
applied to infant feeding. 

1 gram or c.c. of fat equals S.4 calories or 9 calories 

1 gram or c.c. of sugar equals 4.1 calories or 4 calories 

1 gram or c.c. of proteid equals 4.1 calories or 4 calories 



i Archives of Pediatrics, Feb., 1907; also Maynard Ladd, March, 1908. 



THE CALORIC METHOD. 167 



Caloric value per liter o[' the various food: 



Breast milk 650 calories 

Full milk 650 

One-half milk without sugar 300 

One-half milk with ."> per cent, sugar 500 " 

Two-thirds milk with 5 per cent, sugar GOO " 

Buttermilk without sugar 300 

Buttermilk with 5 per cent, sugar 500 " 

Malt soup (formula as given) 700 " 

To Make Malt Soup. 

Cold water , GGG parts 

Full milk 4 per cent 333 

White flour 50 " 

Malt extract (Loeflund's) 100 

Mix flour and water and bring to boil. Then add malt extract stirring con- 
stantly, and bring to boil. Lastly add the milk, stirring constantly. Bring to boil 
three times. Cool it off quickly by standing it in cold water. 

The requirement for the first three months is 100 calories for each 
kilo of weight, for the second quarter year, about 90 calories. 

Later on the requirement is 80 calories, and some infants at end of 
six months do not require more than 70 calories per kilo. Emaciated and 
premature infants require 120 or more calories for each kilo. 

The following case will illustrate the method of caloric feeding as 
used by me in the Babies' Wards of the Sydenham Hospital: — 

Baby B., was admitted to the hospital October 17, 1909. He was a premature 
infant weighing 1.90 kilo. He was fed on a formula containing: — 

Milk 1 ounce 

Sterile water, 4 ounces, with 5 per cent, lactose solution. 

The following table shows the weight and amount of calories given. 

Table No. 33. 
Date Weight 

Oct. 19 1.90 kilos 

Oct. 20 1.94 kilos 

Oct. 21 2.05 kilos 

Oct. 22 1.95 kilos 

Oct. 23 2.10 kilos 

Oct. 24 2.15 kilos 

Oct. 25 2.15 kilos 

Oct. 2G 2.18 kilos 

Oct. 27 2.22 kilos 

Oct. 28 2.22 kilos 

Oct. 29 2.25 kilos 

Oct. 30 2.27 kilos 



Amount of 
Formulae 
19. oz. 


Calori< 
190 


21. oz. 


210 


20.5 oz. 


205 


19.5 oz. 


195 


21. oz. 


215 


19.5 oz. 


195 


18. oz. 


180 


19. oz. 


190 


22. oz. 


220 


25. oz. 


250 


24. oz. 


240 


24. oz. 


240 



168 



INFANT FEEDING. 



Date Weight Amount of Calories 

Formulae 

Oct, 31 2.30 kilos 24. oz. 240 

Nov. 1 2.28 kilos 27. oz. 270 

Nov. 2 2.30 kilos 30. oz. 300 

-Nov. 3 2.30 kilos 36. oz. 360 

Nov. 4 2.30 kilos 33. «*z. 330 

Nov. 5 2.33 kilos 36. oz. 360 

Nov. 6 2.36 kilos 36. oz. 360 

Nov. 7 2.36 kilos 27. oz. 270 

Nov. 8 2.36 kilos 36. oz. 360 

Nov. 9 2.40 kilos 33. oz. 330 

Nov. 10 2.40 kilos 36. oz. 360 

Nov. 11 2.43 kilos 36. oz. 360 

Nov. 12 2.40 kilos 36. oz. 360 

On November 13tli the formula was changed to: — 

Milk 1 V 2 ounces. 

Sterile water 3 1 / 2 ounces, with 5 per cent, lactose solution. 

Nov. 13 2.43 kilos 33. oz. 386 

Nov. 14 2.43 kilos 33. oz. 386 

Nov. 15 2.53 kilos 36. oz. 421 

Nov. 16 2.60 kilos 36. oz. 421 

Nov. 17 2.56 kilos 36. oz. 421 

Nov. 18 2.56 kilos 36. oz. 421 

Nov. 19 2.56 kilos 36. oz. 421 

Nov. 20 2.59 kilos 36. oz. 421 

Nov. 21 2.59 kilos 36. oz. 421 

Nov. 22 2.63 kilos 36. oz. 421 

Nov. 23 2.63 kilos 36. oz. 421 

From a study of the above weight, and the amount of calories fed 
to this infant, we can follow the steady gain in weight. The plan pursued 
was to continue the same number of calories as long as the infant showed 
a gain in weight. For instance: on Xovember 15, the weight was 2.53 
kilos, and ^21 calories were given. Although this same formula was 
continued for one week, the infant steadily gained in weight. 



Milk Idiosyncrasies. 

Some children will not tolerate milk; physicians frequently report an 
intolerance of milk or its dilutions in children. This condition has long 
been known among adults. We frequently hear adults say that milk 
makes them bilious ; that it is not tolerated, and that they feel uncomfort- 
able after a milk diet. While this condition is of much rarer occurrence 
in children, certain cases are met in which milk is not tolerated. It has 
been the milk itself or the component parts of the same that has disagreed 



MILK lDIOSYM RASIES. 



169 



in certain children under the treatment of the writer. Breast-milk and 
several changes of wet-nurses gave the Bame distressing Bymptoms. Cows' 

milk was not tolerated and was discontinued after various dilutions. 

The following ease will serve to illustrate what is meant by the above 
condition : — 



(ask T. — An infant, M. L., was born in July, 1901. The weight at birth was 
About six pounds. The mother had no milk, so a wet-nurse was secured. The infant 
was wet-nursed for the next three months. The child gained about eight ounces 
per week during the month of July, but in August and September it did not thrive. 

History of Food After Weaning. — When the child was weaned, in October, it 
\\.i^ given condensed milk, one drachm to twelve drachms of sterile water, to which 
one drachm of lime-water was added. The child vomited and had eructations, al- 
though it had from one to two yellowish stools per day. When this child was weaned 
it was constipated and required an enema of plain water to relieve the bowel. The 
stools during the summer months contained a great deal of mucus which was 
shredded and yellowish-green in color. The infant was colicky; the stools had a very 
sour smell ; the child frequently had an explosive vomit. The condensed milk was 
continued through the month of October, and, as the child did not seem to thrive, it 
was given Just's Food. This the child refused, so Xestle's Food was substituted and 
seemed to agree. When milk was added the child vomited a sour-smelling liquid, and 
later on refused Xestle's Food. As there was constant anorexia, the child was 
next fed with Ridge's Food. As this Avas not very well borne, a trial was made of 
Allenbury's Food. When this disagreed, the child was placed on Eskay's Albumin- 
ized Food. This also was not tolerated and the child was given some strengthening 
meal. This was not borne any better. 

Examination. — On Xovember 24, the child weighed about nine pounds. It had 
lost eight ounces the week previous to its parents consulting me. This loss of weight 
disturbed the family and caused them to seek a change of diet. The examination of 
the child showed some very interesting facts. First, the general appearance of the 
child was one of an undersized, undeveloped, markedly rachitic baby; there were 
beaded ribs ; the ends of the long bones, particularly the radius, ulna and femur 
were markedly rachitic. Subluxation of the knee-joints was present. The head of 
the child was very rachitic; the fontanel was very widely open; in fact, the 
fontanel was three times the size of that of a normal baby. The extremities were 
extremely cold: the circulation was very poor; the action of the heart was very 
feeble; a blowing murmur was distinctly heard at the apex and could also be heard 
in the vessels of the neck. It was a distinct hsemic murmur and attributed to the 
profound anaemic condition which existed. 

The trained nurse in charge of the case had been with the baby since birth and 
had stated that the child had had a series of spasms which were not only regular, 
clonic and tonic contractions, but they occurred once every twenty-four hours at a 
certain time of the day. The child was very fretful, very nervous, constantly 
irritable and had had very restless spells at night which disturbed its sleep. There 
V«fl a slight eruption around the anus; the child had difficulty in taking the nipple 
■8 well as nursing at the breast. 

An examination of the throat showed congenital adenoid vegetations. This lat- 
fcer condition interfered with the child's proper feeding; it prevented the child from 
properly taking its food and breathing at the same time. It would take the nipple 
or the breast and then let go, in order to breathe. Spoon feeding was resorted to 



170 INFANT FEEDING. 

when the child would not take food from its bottle. Attention was directed to the 
rhino-pharynx. By gradual cauterization the child's condition was so markedly 
improved that its general condition, with the appetite, stools, sleep and weight, all 
assumed normal tendencies. 

Dietetic Treatment. — The child was given the following: — 

]$ Whey 2 ounces 

Milk . 2 V 2 ounces 

Peptogenic powder Half a measure of the metal cap 

Granulated sugar Half a teaspoon 

Mix the above and peptonize the milk by a slow process for about ten minutes 
and when cooled to the proper feeding temperature feed the above quantity every 
three hours. 

The child took the bottle very well ; in fact, took four ounces, retained the food 
and seemed to like it. The following are the nurse's reports: — 

"November 24, 10.30 p.m., took four ounces, has not vomited, seems to like 
food." 

"November 25, 4 a.m., took four and one-half ounces of food, retained. At 
7 a.m. took nearly four ounces, retained. At 11 a.m. child crying and abdomen 
distended, child appears colicky." 

A warm enema consisting of two pints of chamomile tea was ordered so that the 
colon and rectum were thoroughly flushed. The child was instantly relieved after 
some cheesy curds and mucus, plus faeces, were washed away. These fermentative 
conditions, resulting in gaseous eructations, colicky, distended, tense abdomen, with 
crying and occasional cheesy, curdy stools, the temperature frequently reaching 101 
to 103 in the rectum, occasional vomiting and disturbed appetite were invariably 
noticed when milk, peptonized or predigested or in any form, was given to this child. 

It was therefore apparent to me that this baby would not digest milk and hence 
some other form of feeding was required. On December 17th a new form of feeding 
was commenced which is known as a modified form of malt soup. A similar plan of 
feeding is used extensively abroad, at the foundling asylums which I visited; notably 
at the New Berlin Foundling Asylum, which is under the supervision of Dr. Finkel- 
stein. This food is known as Keller's malt soup. Its preparation is rather difficult 
unless performed by a competent chemist. This food has been used for many years 
in the nursling pavilion of the Kaiser and Kaiserin Friedrich Children's Hospital, 
under the direction of Professor Baginsky. 

I am indebted to the New York Walker-Gordon Laboratory for great care in 
the preparation of this food, which has certainly served me very well. The following- 
formula was used in the beginning and was changed, as can be seen by studying the 
accompanying table. 

KELLER'S MALT SOUP. 

Take of wheat flour 2 ounces and add to it 11 ounces of milk. Soak the flour 
thoroughly and rub it through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which add 3 ounces of malt 
extract; dissolve the above at a temperature of about 120° F., and then add 2 x / 2 
drachms of 11 per cent, potassium bicarbonate solution. 

Finally, mix all of the above ingredients and boil. This gives a food contain- 
ing: albuminoids, 2.0 per cent.; fat, 1.2 per cent.; carbohydrates, 12.1 per cent. 
There are in this mixture 0.9 per cent, of vegetable proteids. 



MILK IDIOSYNCRASIES. 



171 



The wheat flour i- necessary, a> other- 
wise the malt soup would have a diarrhoea! 
tendency. The alkali is added to neutralize 
the large amount of acid generated in sick 
children. Biedert emphasizes the impor- 
tance of giving fat. rather than reducing 
it- quantity, in poorly nourished children, 
and rites the assimilability of his cream 
mixture or of breast-milk in underfed chil- 
dren as proof of his assertions. The author 
has used this malt soup most successfully 
in the treatment of athrepsia (marasmus) 
eases in which the children were simply 
starved. 

On studying the ingredients one can 
easily see that the malt extract and the 
dextrinized wheat are highly nutritious 
agents. We know that dextrinized wheat 
is very well absorbed by some of the young- 
est infants. The addition of the potassium 
bicarbonate served to render the food 
markedly alkaline, which is an extremely 
important thing. When milk was added 
with the object of increasing the percentage 
of fat and proteid, we deviated from the 
quantity as originally recommended by 
Keller. Colic and gastro-enteric fermenta- 
tion were invariably encountered. A study 
of the weight chart is extremely interesting. 

Case 2.— The child, S. N., born of 
healthy parents, was put to the breast on 
the second day after birth. On the third 
day after birth there was a profuse flow of 
milk. The infant appeared quite well satis- 
fied after nursing. 

The child Mas nursed every two hours; 
was changed from the right to the left 
breast at every other feeding. Fifteen to 
twenty minutes after each nursing there 
were symptoms of restlessness and constant 
crying. The legs were flexed on the abdo- 
men: there were eructations and all the 
evidences of colic. The child cried at least 
one hour, until it fell asleep from exhaus- 
tion. This state of affairs continued each 
day for at least two weeks. A specimen 
of breast-milk was examined by a chemist 
and found to be perfectly normal in its 
elements and in their relative percentages. 

The family was greatly distressed at 
its continued crying and apparently colicky 




SUNnOcL 



172 



IXFAXT FEEDING. 



condition, but was surprised, in spite of this condition, to find that the infant gained 
between four and six ounces. It was necessary to give 1- to 2- grain doses of chloral 
hydrate at night to procure sleep. We finally decided to change the mother's milk 
and to substitute a wet-nurse. The child behaved just as badly with the wet-nurse, 
had the same crying spells shortly after nursing, which continued frequently for 
one hour. When the breast was discontinued for one day and barley-water or 
albumin-water substituted, the child would appear comfortable, and not have the 
pains which we noted while feeding breast-milk. 

The stool was filled with large, cheesy, curdy masse-. To aid the assimilation 
of the milk, small doses of pancreatin and bicarbonate of soda were given: with the 
idea of partially peptonizing the milk, essence of caroid, a half-teaspoonful before 
each feeding, was also prescribed. In addition thereto small quantities of essence of 
pepsin and hydrochloric acid were given after each feeding, to aid the digestion of 
this food. Xeither of these medications relieved the condition, and I finally decided 
that the breast-milk was not adapted for this child. We next resorted to very 
diluted cows' milk, using one part milk with three parts oatmeal-water. We grad- 
ually increased the strength until one-half milk and one-half, oatmeal-water Avere 
given. 

Table Xo. 34. — Case 2. 





Na of 

Tubes. 




Dex. 


Wh. 


Distilled 


Barley 


Malt 


11* Pot. 


Date. 


Oz. 


Wheat. 


Milk. 


"ft ater 


Jelly. 


Extract 


Bicarb. 






Oz. 


Oz. 


Oz. 


Oz. 


Oz. 


SoL D^m. 


Mav 23. 1908 . 


7 


6 


H 


14 


28 




3 


3* 


Mav 29, 1902 . 


7 


6 


n 


24^ 


171 




2 


3* 


Mav 30. 1902 . 




TV 


n 


85 


14 


Z\ 


2 


H 


Mav 31, 1902 . 


10 


< | 


n 


52 


21 


H 


3 


5i 


June 2, 1902 . 


7 


71 


H 


35 


14 


H 


2 


3^ 


June 5, 1902 . 


7 


U 


n 


35 


14 


4 


. . . 


3* 



Milk, however, in any form, whether diluted or pure, was poorly borne. When 
cereal decoctions were substituted, they were invariably better tolerated. The same 
was true when soups and broths were given. The latter were always well borne, 
and the moment milk was added, no matter in what form, trouble was immediately 
encountered. 

An interesting point is the fact that all infants having the milk idiosyncrasy 
had elevated temperatures ranging from 101 to 102 continuously. 



(TLUTEH TV. 
LABORATORY MODIFICATION OF MILK.l 

It is now several years si nee a Walker-Gordon milk-laboratory was 
established in New York. Their method of feeding infants is based on 
mixing the ingredients in such combination that, when combined, they 
should resemble certain chemical formulae of breast-milk at various ages. 
Blanks are given the physician, which are filled out according to the indi- 
vidual requirement. The age and weight are noted. Fat, sugar, proteid, 
and water are prescribed in percentages. "We are therefore able to state that 
the food ordered contains a definite percentage of fat, sugar, caseinogen, and 
lactalbumm. The same is also true regarding the heating of food. We can 
prescribe the food sterilized, pasteurized, or raw. A -great many changes 
can be made. We can increase or decrease the fat; the same is true of 
sugar and proteids. 

My advice to those using modified milk is to begin with low proteids. 
An infant at birth, if deprived of breast-milk, should never receive more 
than 0.50 per cent, of proteids in the beginning of laboratory feeding. 
Some infants do very well on 0.25 per cent, of proteids soon after birth. 
It is a simple matter to note the infant's condition, its stools, its sleep, and 
its weight. 

If the above-named conditions are satisfactory, then we can increase 
the proteids, the fat, and the sugar. Note conditions every day, and have 
the mother or nurse in charge of the infant report the slightest disturbance. 
Vomiting, if present, its frequency and character, should be carefully noted. 
So also should colicky symptoms, eructations, flatulence, and greenish, 
curded stools. 

Constant crying, disturbed sleep, and restlessness are all factors that 
need correction and supervision. 

The quantity of food prescribed depends upon the requirements of each 
child. Some children can take 3 ounces at one feeding, while others appear 
satisfied after taking 2 ounces of food. 

Examples. — For a child at birth : — 



Fat 2.001 

Sugar 5.00 

Proteids 0.50 

Lime-water 5.00 



Formula I 



1 Reprinted from "Infant Feeding in Health and Disease." Louis Fischer, M.D. 
Third Fdition. F. A. Davis Co., 1903. 

(173) 



174 INFANT FEEDING. 

Or :— 

Fat 2.00 

Sugar 5.00 

Proteids 0.75 

Lime-water 5.00 



^Formula la 



Milk, raw, pasteurized, or sterilized. 

Quantity of food to be given, 2 ounces every two hours. 

My preference for food prescribed at a laboratory where germ -free 
milk is obtainable is to prescribe it raw. When constipation is encountered 
the raw milk will modify such conditions. 

If diarrhoea or looseness exist, then my preference is to use heated 
milk: sterilized from ten to twenty minutes. 

If the infant thrives, the ingredients can be increased; also the quan- 
tity at each feeding: — 

Fat 2.501 

Sugar 6.00 

Proteids 1.00 

Lime-Avater 5.00 

Later, if conditions warrant it : — 



■Formula II 



Fat 3.00 

Sugar 6.00 

Proteids 1.50 

Lime-water 5.00 



Formula III 



In this manner we can gradually increase the percentage of ingredients 
until whole milk is ordered. 

When abnormal conditions prevail — such as loose bowels — -then barley 
water can be substituted for the sterile water. 

Case I. — The following formula was recently prescribed at the labora- 
tory for a child, 1 year old, with very loose bowels : — 

Whole milk 15 ounces 

Pice-water 14 ounces 

Dextrinized wheat 1 ounce 

Dry cane-sugar iy 2 ounces 

Cornstarch 2 teaspoonfuls 

To he thoroughly mixed, sterilized 20 minutes, and divided into five feedings, 
each bottle containing 6 ounces. 

Note. — Successful laboratory feeding will only be accomplished when 
the physician is willing to supervise the products of metabolism and in- 
crease or decrease the ingredients demanded by individual symptoms. For 
example : hard, dry stools, more fat ; a very anaemic condition, more pro- 
teids and fat; a restless, hungry child immediately after feeding demands 
a larger quantity of all ingredients. 



LABORATORY MODIFICATION. i;;, 

When the bowels acted better, and had a more ><>li<l consistency, I a«l<l«'<l 
ixtract, 1 L > teaspoonful to each l»<»ttlc When improvement was noted 
t he above formula was changed t<»: — 

Whole milk 

Barley-water 

( ornstareh 

Dry Bugar 

O \trinized wheat 



"a 


ollll - 


_ 


ounc is 


. 1 


ounce 


i'. 


drachms 


21 . 


i OUD< - 



SI .lize. divide into eight l>ottle< of '» ounces each. 

The following ease illustrates Successful Modified Milk Feeding 
With Milk Prepared at Walker-Gordox Laboratory. 

Case II. — Bahy A., four months old. was seen by me September 19, 1001. with 
the following history: It was the first baby, forceps delivery, podalic presentation; 
weight at birth, about 6 pounds. Family history excellent. Xursed at mother's 
- about four week-, but, owing to a scanty flow of milk, she required addi- 
tional hand-feeding. The baby received milk and barley-water, sterilized or boiled. 
A bottle was given after each nursing i so-called mixed feeding*. 

Result: Constipation: relief given by soap-suds enema. This condition lasted 
about six weeks. The child had colic of a very severe form and also tenesmus: i.e., 
constant straining. 

Child was weaned of the mother's breast: food ordered was: — 

Milk 8 ounces 

Barley-water 16 ounces 

Milk-sugar 3 teaspoonfuls 

Lime-water 2 teaspoonfuls 

Salt 10 grains i pinch ) 

Sterilize thirty minute-, divide into eight feedings, and feed every two hour-. 

When about two months old, child had greenish, spinach-like, very slimy stools, 
mtaining ichitc curds. The infant appeared hungry or thirsty all the time, 
was n stless, had insomnia, and suffered with colic. There was no vomiting. A 
physician ordered the milk discontinued and barley-water given instead. The child 
became extremely emaciated: hence was removed to the seashore. At the seashore 
Dr. J. ordered: — 

Milk 1 ounce 

Boiled water 3 ounce- 
Milk— ugar and salt. 

This food was quite well tolerated. When oatmeal-water was given instead of 
barley-water, to offset the constipating effect, a miliary eruption appeared. 

During the second week of September the child still had diarrhoea. Stools still 
greenish, containing mucus and shreds. The rectum prolapsed from constant 
tenesmus. Cereal milk wa- tried, but with no sue - 

The above is the clinical historv given to me bv the mother of the infant. 



176 



INFANT FEEDING. 



Present condition: A very frail-looking infant, rather emaciated. Poor circu- 
lation, cold extremities, pallor of skin, anus slightly exeoriated, and nsevus on right 
side of thorax. 

Temperature normal in rectum, 98%° F.; pulse, 120; respiration, 28. Throat 
normal, tongue moist and has grayish-white, fur-like coating. Heart-sounds feeble; 
slight bronchitis, diffuse sonorous and sibilant rales heard on both sides of the chest. 
Stomach very markedly distended. Abdomen tympanitic on percussion. Colon dis- 
tended. Liver enlarged. Spleen not palpable. 

. Diagnosis: Chronic dyspepsia, atrophy due to mal-assimilation of food, and 
rickets. 

Prognosis : Fair. 

Table No. 35. 



Weight. 



8 1b. 

9 1b. 



September 19 
September 25 ... 

Gained 

October 2 10 lb 

Gained 

October 9 

Gained 

October 16 

Gained 

October 23 11 lb. 14 oz. 

Gained 12 oz. 

October 30 12 1b. 6 oz. 

Gained 8 oz. 

November 30 15 lb. 7 oz. 

With clothes. 



15 oz. (including shirt and belly-band) 
12 oz. " " " 



10 1b. 



11 lb. 



13 oz. 
2oz. 
6oz. 
9oz. 
7 oz. 
2oz. 
9oz. 



A study of the weight-chart will prove very interesting. 

The dyspeptic and rachitic baby with cold extremities is today a beautiful 
child, well developed, and was not seen by the author for several months — until it 
was necessary to vaccinate. 

Ordered: Syr. rhei arom., 3j every four hours, to cleanse gastro-intestinal tract. 



Also: — 

B Strychnine sulphate 0.002 

Sacchar. alb 0.06 

Decoction of cinchona (fiava) 60.0 

M. Teaspoonful after feeding three times per day. 

The above as a cardiac and vascular stimulant. 

September 20th: Food ordered at Walker-Gordon laboratory: — 

Fat 2.50 

Sugar 6.00 

Proteids 1.50 

Lime-water y 1Q 

Seven feedings of 6 ounces each. Use raw milk. Feed every two and one- 
half hours. 



LABORATORY MODIFICATION. 1 






The following day the child Blept from 8 p.m. till 4 a.m. — eight hours con- 
tinuously. Had three pasty ^tc>ol<. Infant appeared satisfied after bottle. It 
was then ordered i September 22d > : — 

Fat 3.0 

Sugar 6.0 

Proteids 2.0 

Xd alkalinity. 

Raw milk. Seven feedings, 6 ounces in each. 
Feed every two and three-fourths hours. 

Child seemed much better satisfied after feeding; vomited once; had two stools, 
both of yellowish color, and of good consistency. One stool at 5 a.m. and one at 5 p.m. 

September 28th: — 

Fat 3.50 

Sugar 6.00 

Proteids 2.00 

Pasteurize the food. Six feedings of 6 ounces each. Feed every three hours. 
When bowels acted too frequently I pasteurized the food; not otherwise. 

October 6th. ordered: Bran and sea-salt baths every second night: temperature 
of bath 95° F. ; followed by brisk rubbing to stimulate the circulation. The digestion 
of the infant being excellent, stools regular, the percentage of ingredients was in- 
creased: — 

Fat 4.00 

Sugar 6.00 

Proteids 2.50 

Use barley-jelly instead of water-, alkalinity. 5 per cent. Heat to 167° F 

Six feedings, of 6 ounces each. 

Feed every three and one-half hours. 

Child is excellent, gaining in weight: sleeps well: stools normal: has no colic. 
Discontinued laboratory feeding. 

Home modification: — 

Pure raw cows' milk 30 ounces 

Barley-water IS ounces 

Peptogenic powder 3 teaspoonfuls 

Divide into six bottles; warm each bottle before feeding. 
Feed every three and one-half hours. 

Add the barley-water to the raw milk and divide into six equal bottles, then 
place in refrigerator until feeding-time. At feeding-time empty a bottle into a clean 
saucepan, add the peptogenic, and warm to the temperature of 100° F. for ten 
minutes; then boil quickly for one minute and cool to feeding temperature. 

For the relief of constipation: — 

Infus. >enna conip 2 ounces 

• Saccharin 1 grain 

M. Teaspoonful every three hours until bowels move. 

12 



178 INFANT FEEDING. 

After a few days abstracted one ounce of barley-water and added one ounce of 
pure milk, until after a few weeks the child received whole milk, sweetened with one 
teaspoonful of granulated sugar; 8 ounces every four hours. 

Also ordered six ounces of chicken-soup; steak-iuice, gradually thickened with 
cereals; some egg-crackers, zwieback, and bread-crumbs in soup. 

Later: — 

Milk ( raw ) 8 ounces 

Cream % ounce 

Granulated sugar 1 teaspoonful 

Warm in a saucepan and feed every four hours. 

Illustrative Case. — Unsuccessful Laboratory Feeding. — N. R., a healthy 
female, was put, soon after birth, on modified milk. 

October 14th: Fat, 2.0; milk-sugar, 5.0; albuminoids, 0.75; lime-water, y m . 
Eight feedings; 2 ounces in each. 

October 17th: Constipation. Fat, 2.5; milk-sugar, 6.0; albumin, 1.0; lime- 
water, y 1G . Nine feedings; 2 1 /o ounces in each. 

October 27th: Fat, 3.0; milk-sugar, 6.0; albuminoids, 1.0; lime-water, y 1Q ; 
barley-jelly, y 15 . Ten feedings; 3 ounces in each. 

November 5th: Fat, 3.5; milk-sugar, 6.0; albuminoids, 1.0; lime-water, y 1Q ; 
barley-jelly, y 15 . Ten feedings; 3 ounces in each. 

November 17th: Fat, 4.0; milk-sugar, 6.0; albuminoids, 1.5; lime-water, y 2() ; 
no barley. Ten feedings; 3 ounces in each. 

November 19th: Curded stools, dyspeptic diarrhoea. Fat, 4.0; milk-sugar, 6.5; 
albuminoids, 1.0; lime-water, i£ . Ten feedings; 3 ounces in each. 

The child did not increase in weight, had a rectal temperature of 100°, slightly 
furred tongue, vomited curds, had greenish stools containing undigested particles of 
fat and true casein and large masses of mucus. The diagnosis of dyspepsia infantum 
was made; hand-feeding was stopped, the child's alimentary tract was cleaned by 
giving cascara sagrada, and a proper wet-nurse was secured. The infant at this 
time was about six weeks old. The child nursed very well, and after a few days the 
stools were normal, both in consistency and color. The infant gained steadily from 
4 to 6 and sometimes 8 ounces per week, until she was seven months old, when sud- 
denly the weight remained stationary. The child was bright and cheerful, but I 
deemed it necessary to have the milk of the wet-nurse examined by a competent 
chemist; a specimen of the same was secured in the usual manner described by me 
in a previous section on "Specimen of Breast-nulk for Chemical Examination." This 
specimen was examined for the author by John S. Adriance, the chemist of the 
Nursery and Child's Hospital, who reported the following: — 

Fat 2.00 per cent. 

Sugar 7.43 per cent. 

Proteids 0.88 per cent. 

Ash 0.16 per cent. 

Total solids 10.47 per cent. 

Water 89.52 per cent. 

Specific gravity at 70° F 1031 

Reaction alkaline. 

In the chemical result above given it is very evident that a deficiency in the 
proteids exists; hence it accounted not only for the stationary weight, but for the 



LABORATORY MODIFICATION. 17<) 

late dentition. The child did not gain an ounce in one month. We discharged the 
wet-nurse. The following food was ordered: — 

Milk '■> ounces 

Cream - teaspoonfuls 

Oatmeal-jelly ; S ounces 

Lime-water 1 drachm 

Milk-sugar 1 teaspoonful 

Salt 1 pinch 

Pasteurize the above and feed every three hours, the above quantity being for 
one feeding. 

After the infant bad taken this food for six days it was cheerful, had had 
one and two yellow stools daily, and gained 6 ounces in si\ days. 

The above ease will illustrate: — 

1. That the child was decidedly dyspeptic while taking its modified milk for 
about six weeks. 

2. That for about >ix months the infant thrived very well on the milk of a wet- 
nurse. 

3. That the stationary weight of the infant and tne caemical examination of 
the milk of the wet-nurse showed deficient proteids, which accounted for this non- 
increase in weight and the lateness in dentition. 

4. That a proper milk-mixture, which agreed very well, suited the requirement 
of this infant, and emphasizes the fact that we must individualize in each and every 
case. 

It is impossible to make an emulsion like milk from its component 
parts by a synthetic process. Let it therefore be distinctly understood that, 
once a milk emulsion is broken up, as is done iii centrifuging milk and 
removing the cream, mixing the whole will never restore the uniformity 
of the emulsion that existed prior to this division. 

In domestic modification, of course, the same care must be taken to 
secure clean, pure milk and cream from healthy, well-kept cows. This .is 
quite possible now in Xew York, and is becoming easier each year, as more 
attention is being given to infant-feeding and greater demon d is being made 
for a pure milk supply. Pasteurization is as readily done in the nursery as 
in the laboratory. Accurate measurement of quantities and cleanliness of 
vessels and feeding-bottles is equally possible and, in my experience, quite 
as certain at home as in the shop. 

Clinical experience has demonstrated the fact that some children will 
thrive on condensed milk in spite of faulty hygiene, while others will not 
thrive in the best environment with the best form of feeding; again, some 
children will thrive on modified milk; others will not. Some cases seen by 
the author suffered with intense constipation, having clay-colored stools. 
In one instance, in which two children in one family were constantly fed 
on modified milk of varying proportions, the formula? were changed at least 
a half-dozen times with the usual increase of fat and sugar and lowering of 
the proteids. and in spite of this fact, after repeated trials, and no benefit, 
this feeding method was abandoned. A child recently seen by the author 



180 INFANT FEEDING. 

did not gain 1 ounce in four months. This was one of the reasons that 
prompted the family to change both the physician and the food. The child, 
about 2 years old, was very pale, restless at night, quite peevish during the 
day, and decidedly backward in development. It could neither speak nor 
walk, although the teeth were well developed. From the time the modified 
milk was discontinued, and a nitrogenous diet given, the infant improved, 
and from last reports is quite well developed. 

Do not let us blindfold ourselves with the belief that an infant is 
thriving unless our baby shows a regularity in the increase of weight, sleeps 
well at night, for at least from six to nine hours continuously, and, above all, 
assimilates its food, as evidenced by regular, unaided movements of the 
bowels; such movements should be once or twice in twenty-four hours, have 
a yellowish-white color, and a mustard-like consistency. If the stool is hard 
or lumpy or pasty, like putty, then it is certainly abnormal, and shows im- 
proper food. The same is also true if the stool contains white particles of 
cheesy curds, shoiving a casein indigestion. In one infant, which had taken 
modified milk continuously for seven months, an obstinate constipation was 
only relieved after full doses of codliver-oil and extract of malt were given 
for several weeks — aided by massage, besides changing the diet. 

It is therefore very necessary to continually watch the baby, and when 
abnormal conditions such as anaemia prevail, it is wise to give restoratives 
for a long period in addition to the food. Xote if the food is deficient 
in its nutritive elements, and, if so, change the formula so as to adapt it to 
the baby. Do not give medicine when the quality or quantity of food is 
deficient. Remedy the food first; then, if not satisfied, give medication. 

Pallor of the Skin. — An unusual pallor of the skin, and also of the 
conjunctival mucous membrane, has frequently been noticed in modified 
milk babies. In one instance an extreme leucocytosis was noticed, for the 
treatment of which iron was given. An examination of a drop of blood 
showed a diminution of the red blood-corpuscles and an excess of the white 
blood-eorpuscles. A decided haemic murmur was noticeable in the vessels 
of the neck in a child 2 years old which had been fed continually on 
modified milk. 

Craniotabes, softening of the cranial bones, as well as very late closing 
of the anterior fontanel, have also been observed in some children fed with 
this form of food. 

A boy, 4 years old, a typical Walker-Gordon baby, who was fed exclusively 
on modified milk, now shows knock-knees, besides having been under the treatment 
of his physician for a general furunculosis of the scalp. The furuncles were of such 
a size that they required several incisions; others opened spontaneously. 

Sometimes predigested food is ordered with the addition of peptogenic 
powder, the predigestion to be done at the laboratory. A great many phy- 



laboratory modification. 



L81 



sicians who formerly condemned percentage feeding have become converted 
to this method. 

Constipation, which is frequently encountered, can be remedied if the 
chemical and clinical causes are considered. Superheated milk is one of the 

main causes. In spite of the many failures reported by feeding sterilized 
milk, we see hundreds of babies brought up on this line of feeding. 

Chemical changes are produced by subjecting the milk to a tempera- 
ture of '212° F. for thirty minutes and frequently forty-five minutes. These 
changes take place in the most vital elements of milk, such as albuminate of 
iron, phosphorus, and possibly in the fluorine. These elements are present in 
a vitalized form, as they are derived from tissues that contain them. When 
ire consider ttiat children require phosphatic and ferric proteids in a Jiving 
form, then we cannot continue with boiled or sterilized milk feeding for a 
too prolonged period without causing structural weakness. 

There are times when raw milk will cause too frequent stools; then it 
may be advantageous to resort to pasteurization or to heating the milk to 
107° F. for about twenty minutes. 

I am convinced that prolonged, sterilized milk feeding will result in 
rickets. I have had many cases of weak spine and bony structure in which 
nothing but improper food could be regarded as the etiological factor. These 
children were among the well-to-do, among whom excellent hygiene and 
proper nursing habits were rigidly enforced. Improvement was noted when 
sterilized milk was abandoned and raw milk food, in addition to raw muscle 
juice, grape juice, and orange juice, was prescribed. 

A great many unsatisfactory reports are heard regarding laboratory 
feeding. Some condemn laboratory feeding because it is patented. Others 
condemn the method after noting poor results. 

More recently the author has tried raw mill- and cream modified at the 
laboratory, and has noted a great difference in the assimilation of such modi- 
fied milk. Thus, while some experience herein reported has been bad. it 
is possible that a good part of the fault is due to overheating the milk. 
Changing the character of the proteid and altering the chemical relation- 
ship of the various ingredients must change its assimilability, and hence 
the author would urge those who use the laboratory to insist upon having 
formula? compounded by using raw milk and fresh cream. 



CHAPTER V. 
OTHER SUBSTITUTE FOODS. 



Goais- :::i=. 



My experience with goats" milk 

case will scire to illustrate the mann< 

An infant, seven months old, was s 

Lirr=: :;—=■' nilk. ':_: s'^ferei TiziL'tzLz. 
riziir-L =:::•!=. "^TitI. r:::;' nilk ~i; zi' 
aente indigestion subsided. 

Zzl i se::zi vise. :~ :::::::: :ir zi: 
zi~r- :t.L r.:fr:~l — ::"_ 175::-;:::: ::::::'. 
was put to the breast of & wet-nurse. A 
- ■;.-? ?. r;.ir ^ 7: :-:■— s" nil>. mi :_;■:- 
procure a wet-nurse, goats 7 milk dilute 
goats' milk with four ran :^ ; nee wait 
r_r ziiili. sis ii:z.t!i= :li. — : - :~i ::.:r r 
- - i^i::e;.5ri :br ::;-:::- :•:;:.-_: = - i->: 
to three ounces. When the child was ni 
:':: :e~ ninu:^= 3.: 1 Tr:: t-: ;: :rr :: i:f : 
• _t '■?,'-" i rr-in-ri in ~t:^1i : :: i 1: : ~t_- : ~ 



er good. The following 
its 3 milk ^ras used: — 

>r;-:l:::::-, Sir ::.:li no: 
i eone, and had cheesy and 

z'i:- nrl™ is : :~s' r :.-: :1- 

i ~i7ir"T: ::~;" ~:lk ~ .--- 
15 5 : -:l-i ^'_ri -ji- :rJ;.n-. 
nils ~ t:-z\:: -:... :!■= iz.:?.r.: 
eturned. As we could not 
iter, using four ounces of 
r, was given. 
r*fk"> :rriii: 
i-r :::t — j.:cr 
- - -:- ::::rl 



:'r 1. — ::i Tfrr =.2,- 



rli-i: :".:.t :-::ri"z: is =::: m5 Terr =oi.-:-ir. zli :"..;: :: i:\;— ah ::::". iss-rs" 
: --.:'.'.-:. tr'zili zze ::.:i:z :r:n tj.t :-:■— 5' uli is m:re ;:::::;: n: iifz-rilt 
:-: iii-rs: !... _ - : - - :fs:= - - ::i: i'liTcrin =b:~e-i :li: — julr ::~r' ^". k 
was scarcely affected hy it during twenty hours, human, goat, and ; -r5 
zz_i "-:- :::._'.-:-'.' ":_--:t" 

He reports a nnmber of cases showing the remarkable manner in which 
infants thrive on goats 7 milk. The Academie voted in favor of his conclu- 
sions as to the advisability of establishing numerous goat milk depots 
throughout the city. One of the principal advantages of the goat for this 
purpose is that it is refractory to tuberculosis. 



5r=r: 



-- 1 



A very elaborate paper on the subject of buttermilk feeding, by Dr. 
Teixeira de Mattos, of Botterdam, has recently appeared. 3 ~r sites le 



1 Goats' Milk for Infant Feeding. Barbellion (Paris). Bulletin de FAeademie 
Aledecine (Paris). 

2 Jahrhuch fur Kinderheilkunde, January, 1902. 



BULGARIAN MILK. 183 

Jager, who published a paper 1 recommending this form of feeding 
Karger; Houwing, 2 and private and public reports of Schlossmann, 
Heubner, Soltmann, Finkelstein 3 de Mattos, and others. 

Buttermilk. — Take 1 quart (liter) of buttermilk; add 1 even table- 
spoonful of rice, wheat, or other flour desired (about 10 to IS grams) ; heat 
the mixture over a small gas fire, with constant stirring, until it has boiled 
up three different times (requiring about twenty-five minutes); then add 
2 or 3 tables poonfuls (about 70 to 90 grams) of cane sugar or beet sugar. 
It is heller to use uew enameled ware or agate ware for preparing this food. 
The food as above prepared assumes a yellowish color. 

It is necessary to have wide mouths for the bottles as the food coagulates 
and gels lumpy, in which event it would require occasional shaking to bring 
the thickened portion to the proper consistency. 

Bulgarian Milk. 

Milk soured with either a pure culture of the lactic acid bacillus, or 
tablets containing the Bulgarian bacillus, must not be confounded with 
ordinary buttermilk. By the action of the lactic acid on the casein of the 
whole milk, one transforms the casein into a soluble casein lactate. 

How to Prepare. — Boil the milk and, when cool, skim off the skin that 
rises. To one quart of boiled milk add one teaspoonful of pure culture 
of the lactic acid bacillus, or one tablet containing such bacillus, made by 
the Fairchild Brothers & Foster, or by Park, Davis & Co. Set this 
inoculated milk in a warm place for twenty-four to forty-eight hours. 
The lumpy mixture must then be thoroughly shaken, and if of a thick 
creamy consistency must be placed in a refrigerator to retard further 
souring. 

Graanboom, in his book on "Diseases of the Digestive Tract in 
Children" (1901), states that he also is very much impressed with the 
value of buttermilk as an infant-food. 

De Mattos states that children so fed for a period of six to eight 
months show signs of rickets or late dentition, although they look well 
and appear to be well nourished. Whether other methods are worse he 
does not state. 

Lactic acid was never found in the urine of infants fed either with 
lactic acid or its salts. This series of experiments was made by de Mattos, 
and the results were corroborated by Houwing. 

The amount of lactic acid present in buttermilk has been carefully 
studied. Robertson, a chemist, found it to be: — 

Minimum 0.09 per cent. 

Maximum 0.45 per cent. 

1 Nederlandsch Tydschrift voor Geneeskundigebladen, October, 1895. 

2 Centralblatt fiir Gynakologie, 51, 190. 



™ 



184 INFANT FEEDING. 

De Jager believes that good buttermilk does not contain more than 0.5 
per cent, of free lactic acid. 1 These are, however, not absolute and positive 
data, but really individual hypotheses. 

Contrary to the ideas of Munk, Uffelmann, and Ewald (who fear the 
use of food containing lactic acid), de Mattos has found that chronic 
enteritis and gastric complaints soon improve when an exclusive buttermilk 
feeding is resorted to. Hayem and Lesage regard lactic acid as entirely 
innocuous for nurslings. According to the above-named investigators, lactic 
acid is not toxic for infants. They gave experimentally 15 to 20 grains in 
divided doses, mixed with sugar, without seeing any detrimental results. 
Jaworski 2 found no trace of lactic acid in an infant's stomach one hour 
after administering it. 

Eiel maintains that lactic acid improves digestion, while Duclaux 3 
states that lactic acid is a valuable astringent. Heubner 4 found lactic acid 
in the stomach of two healthy infants (to the extent of 0.16 to 0.2 per cent.). 
Marfan (quoting Zotow) maintains that, when lactic acid is found in the 
stomach of infants, it is always a pathological factor. 

Buttermilk in its crude (raw) state is certainly antagonistic to other 
micro-organisms. This is due to the presence of lactic acid bacilli. Eaw 
cows' milk possesses bactericidal properties, but buttermilk is much more 
bactericidal. The latter, sterilized with the aid of steam, showed virulent 
typhoid bacilli nine days after being inoculated with the same. In non- 
sterilized buttermilk (raw state) virulent typhoid bacilli lost their virulence 
after two days, and when put into the brooding oven lost their virulence 
after twenty-four hours. The bacillus lacticus of Pasteur and Hueppe seems 
to be identical with the bacillus lactis aerogenes of Escherich, 5 which is 
found in the upper part of the small intestine. 

Jaworski found that pepsin is more readily secreted when lactic acid 
is given internally. De Mattos states that he has never met with a case of 
Barlow's disease among infants fed with buttermilk. 

Disagreeable symptoms are frequently encountered for the first few 
weeks while giving buttermilk. Such are frequent vomiting and diarrhcea. 
These are not contra-indications for feeding, and, notwithstanding the 
presence of the above-named symptoms, the feeding should be continued. 
If, however, the symptoms are very severe, then the administration of astrin- 
gents — such as bismuth, argent, nitrate, tannalbin, or iehthalbin— may be 
required for temporary relief. 

An important point is that in this form of infant-feeding the large, 



x Xederlandseh Tydschrift voor Geneeskimdigebladen. 1899, i. S. 945. 

- Deutsches Archiv fur kliuische Medicin, Bd. xxxvii, i. 

3 "Maladies de l'Enfance," tome ii, p. 60G. 

4 "Jahrbuch fur Kinderheilkuude," 1891. 

5 "Die Darmbacterien des Sauglings/' Stuttgart. 1886. 



BUTTERMILK FEEDING. 



is:, 



thick, cheesy curds so commonly met wrth in dyspepsia and diarrhoeas in 

feeding with cows' milk arc never seen. Children thus fed seem to with- 
er 

stand the infectious diseases very well. A point worth noting is that when 
a child is more accustomed to buttermilk feeding the change to sweet milk 
will cause diarrhoea. 

When we find that the weight is not increased and we desire to change 
to sweet milk, the latter should be gradually added to the buttermilk in- 
stead of making a distinct change suddenly. 

Quality of the Buttermilk. — This is the most important part of our 
subject. In securing our food we must be sure that we are dealing with 
honest dairymen whose sole object is to deliver what is demanded for weak 
infants. Stale combinations made by the use of left-over centrifugal milk 
or skim-milk or spoiled milk which cannot be used otherwise should be 
inquired into and rejected. 

Good buttermilk can be made from either whole milk or from cream. 
In Holland buttermilk is made by pasteurizing cream in Timpe's apparatus 
and then inoculating and buttering the same with a pure culture of lactic- 
acid bacillus. In order that raw milk will yield buttermilk a certain per- 
centage of acidity must be present. 

The usual precautions in milking (so-called modem stable hygiene) 
must be observed in securing milk to be used in making buttermilk. The 
milk should be received in sterile vessels and rapidly cooled, and should then 
be kept in cool cellars or ice-coolers having a low temperature (no higher 
than 15° or 20° C.) for eighteen to twenty-four hours. It is necessary to 
stir the milk occasionally. Rapidity of souring can be assisted by adding 
sour milk or by inoculating with a pure culture of lactic-acid bacilli. Xo 
definite rule can be laid down as to when buttering takes place; empiric 
methods must decide this matter. This is due to the size of the vessel used 
and the influence of seasonal changes, and also the amount of churning it 
had received. Cows' milk which contains colostrum or which is bitter is not 
adapted for buttering. 

Butter should form in small, pin-head-sized particles in thirty to forty- 
five minutes. It is regarded as a mistake to have large particles of the size 
of a pea or larger, and dairymen look upon such buttermilk with suspicion. 
Buttermilk in general contains about 0.3 to 0.4 per cent, of fat. 

Escherich states that the fermentation of milk is due to the splitting 
up of the inilk-sugar, whereby lactic acid, 0, and C0 2 are formed in the 
intestine. 

Table No. 36, on following page, is instructive in showing the per- 
centage of acidity present and also the difference in fat. 



186 



INFANT FEEDING. 



Table No. 36. 





Specific 
Gravity. 


Solids, 
Percentage. 


Fat. 


Acidity According 
to Soxhlet-Henkel. 


Sour milk before 
buttering 


1.029 


11.40 


2.8 


18.1 


Buttermilk 


1.029 


9.60 


0.5 


16.1 



There is, therefore, a difference of 2 per cent, in the amount of acidity 
present in favor of buttermilk. 

An important point is to overcome the Jumps usually found as coarse 
coagula in buttermilk. De Hattos advises adding flour — cither rice, wheat, 
or lentil — or even some proprietary infant foods, according to the require- 
ments of the infant. 

This is merely given to hold the noceuli in finer form and to prevent 
their coagulation into lumps. Dyspeptic children with subnormal digestive 
powers should receive a minimal quantity; thus, an even tablespoonful, 
amounting to about 10 grams, will suffice. 

Addition of Sugar. — The quantity of sugar to be added must be reck- 
oned empirically; thus, 3 tablespoonfuls, about 90 grams, are required to 
each liter (quart) of buttermilk. Barely do we need more than 100 grams. 

Cane-sugar or beet-sugar serves best for sweetening. Sugar cannot be 
found in the urine nor in the faeces of infants fed on buttermilk to which 
sugar was added. 

The results which might be expected from using cane-sugar — such as 
diarrhoea, fermentation, sour eructations — are totally absent in using butter- 
milk feeding. 

Stools. — The average buttermilk-fed infant has no more than one or 
two stools daily. They are more or less solid in consistency and have an 
all-aline reaction. It would be incorrect to state that all children fed with 
buttermilk must have yellow stools. We know that even Uffelmann, in his 
studies of infant-stools, states that breast-fed infants show great variations 
from apparent normal stools and still thrive. We also know that bottle- 
fed infants reared on cows 7 milk have no definite hind of stool which we 
could call a standard stool. Still, the buttermilk-fed infant never has the 
coarse casein particles in the fa?ces that we see very frequently in the stools 
of infants fed on cows' milk. 

The bacteriological examination of the fasces made by inoculating 
gelatine plates with diluted fasces showed : — 

1. Liquefying colonies rendered Loefner's nutrient gelatine strongly 
alkaline. Inoculated into bouillon, the latter remained clear, forming a 
skim on the surface. Milk was not coagulated by these micro-organisms. 



I.AIIMANN'S VEGETABLE .MILK. 



187 



They formed spores, generated 



ILS, and can therefore be identified as the 
bacillus butyricus of Hueppe. 

2. Non-liquefying colonics were inoculated into milk-sugar bouillon and 
left in the brooding oven over eight hours at 37° C. All tubes so treated 
were turbid on standing over night; this fact excludes the possibility of its 
being the bacterium coli. 

Other properties were found, such as : fermentation in milk-sugar 
bouillon, no skim forming on the bouillon; indol does not form in peptone 
solution (bacterium coli would form indol); milk turns sour but slowly; 
no NH 3 formation. 

From a study of the above properties we conclude : — 

1. Bacterium coli commune must be excluded. 

2. Bacterium coli lactici (Hueppe) (resp. bacterium lactis aerogenes, 
Escherich) must be identified. 

The lactic acid bacillus, found in boiled as well as raw buttermilk, loses 
its potency in the intestinal canal in the presence of the bacillus butyricus 
(Hueppe). The latter germ grows in overwhelming numbers and renders 
the intestinal contents rapidly alkaline. 

An interesting point is that, if the buttermilk was originally very 
sour, the fa?ces will be very alkaline, showing how weak the bacterium acicli 
lactici is. 

Feeding. — The writer has seen excellent results from buttermilk feecling 
in atrophic and marasmic children. As an article of diet during convales- 
cence after pneumonia and typhoid fever the results were encouraging. 

Quantity to be Fed. — Buttermilk as above prepared should be fed 
exactly as would other milk. Four ounces, increased to 5 or 6 ounces, can 
be fed every 3 hours, or the interval may be prolonged to 3y 2 or 4 hours. 
It will be necessary to coax the child in the beginning with this new form 
of feeding, owing to the difference in the taste of fresh milk and butter- 
milk. 

Lahmann^s Vegetable Milk. 

In Europe, and recently also in our country, the feeding of infants has 
been enriched with a new product ; thus, Dr. Lahmann believes that the 
great panacea is feeding infants with milk which he designates as '"vege- 
table milk." It resembles a thick jelly, and is made by Hewwel & Veithen, 
of Cologne. His theory consists, in brief, in substituting nuts and almonds, 
which are rich in albumin and fat, instead of cereals to dilute milk, his 
idea being that an emulsion which is digestible and supposed to be rich in 
albumin is doubtless better than pure water or a thin starch paste. In 
order to add food salts, which are not supplied by this means, he extracted 
them from leaf vegetables, which are rich in food salts, and added some 
sugar syrup. Tn this manner he claims to have made a preparation which 
he states is chemically equal to human milk, and full of nutritive value. Hi? 



188 INFANT FEEDING. 

idea is that the interposition of plant-albumin (eonglutin) particles, which 
coagulate with difficulty between the coagulating casein masses, would in- 
crease their digestibility by breaking them up, and that the digestion of the 
plant-albumin and oil, as well as of the sugar and food salts, would present 
no difficulty. 

Stutzer, of the University of Bonn, reports thus: The vegetable milk 
is distinguished from children's food by the absence of starchy substances. 
In common with Bieciert's cream mixture, the vegetable milk contains con- 
siderable quantities of fat in an emulsified condition. It differs from the 
cream mixture in the way it is prepared, and in its other qualities. 

Chemical Analysis. 

Fat . 34.72 per cent. 

Plant-casein and similar nitrogenous constituents . . 12.00 per cent. 

Sugar and plant-dextrin 31.02 per cent. 

Salts 1.64 per cent. 

Water 20.62 per cent. 

ILy own personal experience has been rather favorable with the use of 
the vegetable milk, inasmuch as an emulsion of almonds and nuts was used 
to dilute the curd of cows' milk. Thus, equal parts of vegetable milk with 
cows' milk were taken by an infant for several months, and it was very 
well assimilated. Xot only did the child gain in weight, but the bowels 
were in a fair condition, and the infant remained strong. My experience, 
however, is too limited to give a positive opinion. 

Gaertxer Mother Milk. 

Several years ago I was persuaded to use Gaertner milk in a series of 
cases. The milk was sold in tin cans. The manufacturers would not take 
the advice given them, to use fresh mill- and deliver the mill- in clean 
bottles daily. Such food as "milk sealed in tin cans" cannot be recommended 
for healthy and certainly not for sick infants. 

In the Medical Record, December 11, 1897, I published a paper enti- 
tled "The Clinical Value and Chemical Eesults of Gaertner Mother Milk." 1 
This food has now been used several years in Europe, and is the out- 
come of the scientific endeavors of Professor Gaertner, of the University of 
Vienna. The first paper was published by Gaertner in the Therapeutische 
Wochenschrift, May 5. 1895. 

A few months before, January, 1895, Gaertner, in an address before 
the Vienna Scientific Society, explained the mode of preparation and the 
results obtained with his new modification of cows' milk, for such the 



1 Those interested are referred to my paper, entitled "Gaertner Milk," containing 
an elaborate chemical report by Professor Poole. Xew York Medical Record, Decem- 
ber 11. 1897. 



(i \KKT.\KK MOTHER MILK. 189 

mother milk of Gaertner really is. Professor Gaertner, in the preparation 
of his food, has aimed to overcome what has been the great difficulty in 
infant-feeding — namely: to reduce the excess of casein by a scientific process 
without the addition of chemicals. 

To achieve this result he employs a machine called a separator or 
Pfannhaiiser centrifuge, which makes 4000 or 8000 revolutions per minute. 
The apparatus consists essentially of a drum of steel, which revolves on its 
axis. This drum is filled with equal parts of fresh cows' milk and sterilized 
water. The mixture contains approximately the same amount of casein as 
human milk, for cows' milk undiluted contains about twice as much casein 
as human milk. The mixture is next poured into the centrifuge and the 
speed of the drum is carefully regulated, so as to separate the mixture 
contained therein into (1) a creamy (fatty) milk and (2) a skimmed milk. 
The two portions so separated are then led off separately by suitable open- 
ings in the centrifuge. 

The analysis of each of these portions shows that the creamy milk has 
the same quantity of fat as is found in human milk, while about 2 per cent. 
of the casein is contained in the skim milk, and the remainder, about 1.7 
per cent., remains in the creamy milk. The chemical composition of fat 
milk is shown in the following table : — 

Table Xo. 37. 

Proteid. Fat. Sugar. Ash. 

Fat milk 1.76 3-3.5 2.5 0.35 

Human milk 1.03 3.5 7.03 0.21 

Cows' milk, diluted with one-half water... 1.76 1.6 2.5 0.35 

If, now, 3 or 4 grams of milk-sugar be added to every 100 cubic centi- 
meters of fat milk, the percentage of sugar is brought up to the level of sugar 
in human milk. This addition is made before sterilizing. The fat milk 
has the advantage over the diluted milk of having "a higher percentage of 
fat"; it also curdles more slowly than diluted milk and the curd forms a 
more flocculent precipitate. 

Baginsky 1 mentions Gaertner milk as a new form of food introduced. 
In our country Jacobi 2 states that Gaertner milk is applicable to the ma- 
jority of infants who require cows* milk appropriately prepared. A few 
years ago I subjected the milk to a very rigid test from June to October, the 
worst months for milk digestion. The hygienic conditions of the infants 
were those found in the average tenement house, too well known to need 
description. 

The guides for ascertaining the degree of assimilation were the follow- 
ing factors : — 

1. The child's general condition, as manifested by its appearance, ap- 
petite, and sleep. 



1 "Lehrbueh der Kinderkrankheiten," fifth edition, pages 35 and 36. 

2 "Therapeutics of Infancy and Childhood." page 508. 



190 INFANT FEEDING. 

2. The presence or absence of gastro-enteric disturbances, such as vom- 
iting, colic, restlessness. 

3. The condition of the stools, constipation or diarrhoea, the number 
of stools in twenty-four hours. 

4. The gain in weight; weekly observations. 

The nurses or mothers were instructed to note the amount of food taken 
and the number of stools in twenty-four hours. 

We submitted the stools passed in twenty-four hours to Mr. Herman 
Poole, our chemist, whose chemical report 1 is of interest. We tried to 
ascertain how much proteids, fat, sugar, and salts were taken, how much 
absorbed, and how much was voided in the faeces after having taken part in 
metabolism. 

Backhaus's Milk. 

The following method is employed in the production of this food. 
The milk from different breeds of cows is mixed and passed, through a cen- 
trifuge, to separate the cream from the milk and to remove any impurities 
that might have gained access to the milk, notwithstanding the great care 
used in handling. Three grades are produced : two for infants, the third 
representing full milk in its composition. After separating it from the 
cream the milk is exposed to the action of a mixture of rennet, trypsin, and 
sodium carbonate, which are combined in such proportions that the trypsin 
will have converted at the end of thirty minutes 30 per cent, of the casein 
into soluble albumin. By this time the action of the rennet coagulates the 
balance of the casein and thus arrests the action of the trypsin. The tem- 
perature of the mixture is now raised to 80° C. (176° F.) by the introduc- 
tion of steam into it. At this temperature it is kept for five minutes. At 
the end of this time it is strained through cloths and mixed with half its 
volume of water, one-fourth its volume of cream, and the necessary amount 
of sugar of milk. It is finally put up in bottles holding 125 grams (about 
4 ounces) and sterilized. 

The second grade, for older children, is obtained by mixing equal 
parts of milk and water with half the quantity of cream and with milk- 
sugar. This is put up in quantities of 200 grams (about G 1 /*? ounces). 

The third grade, in bottles holding 300 grams (about 10 ounces), rep- 
resents cows' milk in composition, modified by the above-mentioned process. 
The composition of the three grades is given as follows : — 

Fat , 3.1 3.2 3.3 

Sugar of milk 6.0 5.4 4.8 

Casein 0.0 l.S 3.0 

Albumin . 1.0 0.3 0.5 

Ash 0.4 0.4 0.7 

1 New York Medical Record, December 11, 1897. 



CONDENSED MILK -CONDENSED CREAM. 



191 



The milk 1ms been tried at the Wiener allgemeine Poliklinik by Friih- 
wald in a series of twenty cases, the histories of which arc given by the au- 
thor. With the exception of six, these children have been under observation 

for more than two months. When first seen the children were all Buffering 
from different forms of digestive disturbances, and from malnutrition; 
some were suffering from severe marasmus, and most of them passed through 
some other disease while they were under observation. Three of the infants 
took the breast in addition to the Backhaus milk for periods of two and three 
weeks, when they, too, had to be put on the artificial milk entirely. The 
children took about six bottles of No. 1 up to four weeks; seven to eight to 
the end of the second month. From the middle of the third month the 
second grade was gradually substituted, while Xo. 3 was used only in the 
case of an older child. A daily gain was observed of from 18 to 30 
grams (about % to 1 ounce). In private practice and in healthy children 
a gain of 50 grams (about 1V> ounces) not rarely happens. The milk 
keeps well. 

Ooxdexsed Milk ok Ooxdexsp:d Cream. 

Hundreds of infants are fed with condensed milk. This has its 
reasons : — 

1. The readiness with which condensed milk is obtained. 

2. The great cheapness of this article. 

3. The ease with which the feeding mixture can be prepared. 

Jacobi says that some manufacturers use pure cows' milk; others find 
it in accordance with the health of their bank accounts to use skimmed milk. 

Quantity of Sugar in Condensed Milk. — Milk sold in our city for im- 
mediate use contains about 12 to 15 per cent, of sugar. Milk to be kept for 
an indefinite time contains as much as 50 per cent, of sugar. These varia- 
tions show how serious it is to use the same quantity of condensed milk all 
the time and from different sources with such an enormous variation in the 
quantity of sugar. 

Kehrer — quoted by Jacobi — states, regarding it, that it increases the 
formation of lactic acid. Fleischman states that it gives rise to thrush and 
diarrhoea; Daly, that it fattens them ( ?), but gives rise to rachitis. 

The worst specimens of rachitis and spinal rickets seen in my clinic 
are in condensed-milk babies. Our medical literature reports many cases 
of apparent health in infants fed on condensed milk. It has led Des- 
sau, with a large experience with infants, to mention such a method, al- 
though he advocates cows' milk, properly modified, for continued use. 1 

In traveling, when good fresh cows' milk cannot be obtained, then I 
permit the use of condensed milk, but for a few days or for a week only, 
as on the ocean steamer, where cows' milk cannot be had. 



1 See my paper on infant-feeding (read before the Society for Medical Progress, 
April 11, 1896), published in extenso in Pediatrics for July 15, 1800. 



192 



INFANT FEEDING. 



My experience among thousands of children seen in niy Children's 
Service at the German Poliklinik and also at the service at the West-Side 
German Dispensary during these last fifteen years has been that children 
so fed have rickets; that they are predisposed to the infectious disorders; 
that they have less resistance and far less vitality, especially in combating 
such diseases as pneumonia or diphtheria; that they have tendencies to 
hernias and deformities, owing to the softer condition of their muscles and 
bones; that they invariably suffer with constipation, alternating with diar- 
rhoea; that their dentition is delayed, compared with other methods of 
hand feeding. Thus summing it up, I cannot approve of this method at 
all. 

Condensed cream will be lauded by the mother whose baby is well, and 
again the same food will be condemned by the mother of an infant whose 
rickety head, bones, and muscles are founded on an impoverished diet of 
condensed milk. We can account for the rickety child, but we cannot 
account for the healthy one on the same food. 

The directions on the tin of the Anglo-Swiss Condensed Milk Com- 
pany's Milkmaid Brand of condensed milk are, for new-born infants, add 
14 parts of water; as the child grows older, gradually use less water, but 
never less than 7 parts. 

The analyses of all these condensed" milks are of the milk diluted with 
7 parts and 1-1 parts of water — the two extremes. 

The following brands of condensed milks are considered to be among 
the best upon the market. 

Table No. 38. 





Milkmaid Brand. 


Gail-Borden Eagle 
Brand. 


Nestled Swiss Milk. 


Woman's 
Milk. 




With 7 


With 14 


With 7 


With 14 


With 7 


With 14 






PartsWater. 


Parts Water. 


PartsWater. 


PartsWater. 


PartsWater. 


PartsWater. 




Water . . • 


88.18 


93.59 


89.10 


94.09 


87.95 


93.46 


88.51 


Ash ... 


0.36 


0.19 


0.29 


016 


0.25 


0.14 


0.34 


Proteida . . 


1.50 


0.82 


1.31 


0.71 


1.51 


0.82 


2.35 


Fat ... . 


1.70 


0.92 


1.18 


0.64 


2.14 


1.16 


2.41 


Cane-sugar . 


6.00 


3.25 


6.59 


3.57 


5.81 


3.15 




Milk-sugar . 


2.26 


1.23 


1.53 


0.83 


2.34 


1.27 


6.39 



On studying the clinical relationship of the component parts of con- 
densed milk, it is very apparent that, diluting the Eagle brand of condensed 
milk with 14 parts of water, we have but 0.7 per cent, of proteid, 0.6 per 
cent, of fat, and 3.5 of sugar. The deficient bone-building and muscle- 
forming ingredients account for the rachitis which invariably results. 



I 



CHAPTEE \ 'I. 

PROPRIETARY INFANT FOODS. 

Patent Foods. 

Th kiji: are a great many infant foods in use at the present time. Xo 
one will question the large amount of foods sold. This is due to several 
reasons: First, because the laity have been educated to use them, when 
cows' milk or even when breast-milk, in rare instances, disagrees; second, 
physicians of large experience advocate the use of a great many patent foods. 
When disturbances in the stomach or intestines interfere with the proper 
digestion and assimilation of the proteids, then frequently the modification 
of the milk, by the addition of these foods, yields good results. In some 
instances where there is no appetite w^e frequently can stimulate an appetite 
by advocating the temporary use of these foods. 

In the large cities where breast-milk is unobtainable for infants, these 
foods are frequently given. 

During the course of summer complaint, typhoid fever, or acute infec- 
tious diseases, I have frequently advised the use of diluted milk with several 
teaspoonfuls of a nutritious food, rich in barley malt. The objectionable 
features of patent foods consist in the ease with which they are procured, 
and the careless manner in which they are given. Thus, a large portion of 
the laity will follow the directions on the label of the box of patent food 
to the detriment of the child. Many a case of rickets or scurvy can be traced 
to ignorance in giving patent foods. We know, however, that there are some 
virtues hi these patent foods, and to attribute all cases of rickets or scurvy 
to this one cause is w r rong. Investigations made by the American Pediatric 
Society showed that a large number of children fed on sterilized milk suf- 
fered with scurvy. A great many facts must therefore be considered before 
condemning or praising one or all of the foods. The intelligent physician 
knows that raw milk or milk warmed to blood heat possesses anti-scorbutic 
properties. When a given commercial food is added to raw milk, thoroughly 
mixed, and heated to blood heat or to a pasteurizing temperature, we still 
retain the virtues of the milk and increase its nutritive value with the aid 
of the food selected. Roughly speaking, there are tw r o kinds of infant foods 
on the market : (a) Infant foods to be used as adjuncts to fresh cow T s' milk. 
(b) Infant foods in which desiccated cows' milk is a constituent. 

These foods are commonly known as dried-milk foods, although in this 
class of foods milk solids constitute but from one-eighth to one-fourth the 
substance of the foods, the balance consisting of matters derived from 
cereals. In some of these foods the starch of the cereals is untransformed, 
and they may be termed farinaceous dried milk foods. In others the starch 

13 (193) 



1.-4 :: :— : rzzziz:- 



of the cereals Ins been transf o-imed into dextrin and maltose, and they 

:e zrzr-1 zzzzi zzl zzz ::< 1= 

- - ^ z_ . . : - : l - : . _ - - 

Izz ':■--'_-_ z zz :lr :z z iz: ...zi zzz ••: . _ :: - : :zzzl zz z. 
z_ I zz :.-r - zzzz L;es zz . -.*-.z\ z-zz ._ ~zz z zz ".: z__ 
". :-:«:ess ":::: - zz : II _\._ zzliz.z Lz :_•- Izzl milk ::«zz zz ..>-•;-. z 
zzz: ;: :_ T - ~z mill is ::v :-l " zz. 

".'.:: :z :i:ll-::lil zzzzzz . Li :7Z ':-: 1. inJ _: is z zz f.zzz z z_7. 
Izzz z zzz ; zzzz r-f-r - zz__z - '.v. '■'.- zz - zz: 

1_T _- : iniinr . 1 ■■ - :::? :■; ~= z zl> :.:- zzz-z 

zzzz. z : .1 ziz :: z :-:.. ; zi : ...-.-z. _ . -£r-~ : zz: i _ z:e: 
starch, or malted fool s made from cereals, but baring the starch 

-: zz zz Til :z: -1: z zzz z zzi zzzzz _-_; iresl . ~- zzz z. ~zz- 
:~z i : If 7-- rzzzzlz zzziz z _ 7.:: : : z- zz:;:i : zzzzz 
:: zzmzz :1: :■".-:: zz zzz :zz :-l ::: :":: z zz zzz :: zzl 

. z - i - 

i. :z 7 i. z zk :•: ■!= 

zz z 7 - -.7 zzz -. : zzz: ::•:!- :zz: lz~z i-rti zz :z Zt zzizz 
.- .- - : - _ 7 : :-.-- : ■ I :zz : 

;\:i_7 :zzz z zz zz.::: z zzz : zz zz: z: : :-l z_l :z z-„ izz 
z ~:zzz - z:i> z = ..- . r-- z - z -:z ~ izs :•: _. z zz z ..zz z- ; zzzzzz 
: : Zt -Z-.:..- '-7 z z: ... z z.r zzzzz- : z- „zzzzzz:. zz I 
the analyses- that accompany the following descriptions are of the foods 
.zzz-l : : - . : z z- -zz z zzz : zz - -. zzre..zi:zi z :!-? 



: 7 Intavi z : •:: - 

Ilr I i ~ - ' . . .-" : Z Z : Z Z ZZ ifZ 1ZZ:ZZZ TZr7-r iZr 

zz f:zr z z~- : z : : :■- --'. ._ z :zz:z z :.z.: i zz: 
1 ; : : .7 1 — 

1 . - . - V : 

Ez" 7. - ~ '1 - ri r.l :■:« i zzrl -ItZ 

Wampolcfs 11 zz 7:>od (composed of predigested eeieals, bee-f^. and 

~"-t:z"j !z- z" F :•:-.: :«:zz-zzl : zz: zz •: zi - 1 
JdsPs Food (partially pre<ligested cereals. To he nscd with milk) . 
HiZciilz zz. " i z_l :zzz:z "z-izzz . 
HoriieFs Food (predigested. to he added to milk). 
llzlzz's 7" Z:':z--zz:"rzli". z:z: . 
Imperial Grannm (baked wheat). 

'_" --z-; F:o«I :• z-.-z " iziilz z ..----" zi I: z 

milk). 

l;z:.zlzz:rzz i:zl zz 

Lactated Food (farniaceoiis wifli miTV-sngar). 



Ridg I (farinj 

_ dc Milk Powder (t<> modify milk). 
_ : - e modify the casein of cows* milk). 

Zimmerman Barley < >at F< 
Xutrieo Fo ad). 

Lange's Tissue Food (a condensed milk). 
Hayes's Oai 1). 

A'.'enbury's Milk Food, No. 1 (predigested; prepared with wal 
contains dried milk). 

Allenbury's Milk Food. Xo. *2 (predigested; prepared with w 
contains dried milk). 

Allenbury's Malted Food, N rtially predigested: prepared with 

milk 

Benger s Imported ( cereal and not predigested ) . 
Xeave's Food. In: rt farinaceous . 
- :ay"s Albuminized Food, 
al Milk. 
Carnriek's Soluble Food. 
Diastased Farina. 

xmbs's Malted Food. 
inson's Groats. 
inson's Patent Bar! 
Chapman's Whole Flour. 
- tfa Flour. 

Milkine. 

The published analyses of woman's milk show the great variability of 
i illy as regards the percentage of proteids and fats. 
The analysis of woman's milk used in the following tables is by Dr. Luff. 
adopted as the standard by Cheadle. It agrees closely with Leed's analysis, 
excepting as to the fat. which is given by Luff as 2.41 per cent, and by 
Leeds as 4.13 per cent. : the latter amount seems too large, as it exceeds 
considerably the published aver; _ a fa number of o - 

Nestlb's Food. 

Nestled food is a farinaceous dried milk food. According to the manu- 
facturers, it is made "from the richest and pur-- milk, the crust of 
wheaten bread, and cane-sugar.*' and is a "form of modified milk." "X > 
-" milk is to be added to Nest - 1; nothing but water, and that water 
is boiled.*' 

n examination, unconverted starch and cane-sugar are found to be 
incipal constituents, amounting to about TO per cent, of the whole. 
The directions for preparing X sfcle*s food for the nursing bottle, for in- 
fants six months old. are to ua 1 tablespoonfuls of the food to % 



196 INFANT FEEDING. 

pint of water; mix the food with enough warm water to make a- smooth 
paste that will pour, add the rest of the water and boil in a saucepan, stir- 
ring constantly until it thickens and a milky foam appears on the top. 

Table No. 39. 

Composition of Xestle's 
F o o (7.1 when Pre- 
pared as above. Woman's Milk. 

Water 92.76 88.51 

Salts .-.-... 0.13 0.34 

Proteids 0.81 2.35 

Fat . 0.36 2.41 

Starch 1.99 

Cane-sugar 2.57 

Maltose, dextrin, etc 0.44 

Milk-sugar 0.84 6.39 

Reaction alkaline. Reaction alkaline. 

The mixture owes its thick condition mainly to the insoluble starch 
present. The total carbohydrates therein (5.84 per cent.) are somewhat 
less than the carbohydrate, milk sugar (6.39 per cent.), in woman's milk: 
it is to be noted that of this amount 1.99 per cent., or about one-third, 
consists of insoluble starch. 

The fat is nearly one-sixth and the proteids are about one-third of 
the amounts in woman's milk, and over one-half of the proteids is 
insoluble, owing to the colloidal condition of the milk-casein having been 
destroyed by drying during manufacture. 

Hoelick's Malted Milk. 

This is a dried milk food, said to be composed of pure, rich cows' 
milk combined with the extract of malted grains, and not to require the 
addition of milk, nor any cooking. The manufacturers claim that by 
their methods and apparatus, the proteids are rendered very digestible 
and do not form large, irritating curds in the stomach. 

The directions for preparing the food for an infant six months old, 
are to dissolve 3 to 4 heaping teaspoonfuls in ±U 2 to 6 ounces of water. 

Table !Xo. 40. 

Horlick's Malted Milk. Woman's Milk. 

Water 86.29 88.51 

Salts 0.5a 0.34 

Proteids 2.31 2.35 ' 

Fat 1.24 2.41 

Carbohydrates 9.61 6.39 



This product is very nearly soluble in water, as its principal con- 
ents are the soluble 

i According to Chittenden. 



stituents are the soluble carbohydrates — maltose, dextrine, and milk 



MILK INK. Jf)7 

sugar. The drying process is said to be conducted very carefully in a 
vacuum, and hence tne solubility and digestibility of the product, it is 

claimed, arc not lessened. 

The proteids arc aboul the same as in woman's milk, but the fat is 
about three-fifths and the carbohydrates are about five-thirds as much as 
woman's milk. 

When cows' milk causes continued constipation, the substitution of 
a bottle containing hot water 8 ounces, in which -4 teaspoonfuls of malted 
milk are dissolved, arc indicated. It acts as a corrective, as the maltose 
has a laxative effect. 

Milkine. 

This is a malted dried milk food. Its makers state it is a complete 
food ready for immediate use by the addition of water, and the only pre- 
pared food that combines the nutritive elements of meat, milk, and 
cereals. 

In this malted dried milk food, beef extract is combined w T ith cereal 
extractives and dried milk. Soluble carbohydrates are its principal constit- 
uents, forming nearly three-fourths of the product. The proteids are spar- 
ingly soluble. 

The directions for preparing milkine for an infant three to six months 
of age are to dissolve 1 to 2 dessertspoonfuls of food in a breakfastcupful of 
water. 

Composition when prepared with 2 dessertspoonfuls in a breakfast- 
cupful of water : — 

Table No. 41. 

Milkine. Woman's Milk. 

Water 92.78 88.51 

Salts 0.23 0.34 

Proteids 0.92 2.35 

Fat 0.43 2.41 

Maltose, dextrin, etc 4.74 

Milk-sugar 0.90 6.39 

Reaction alkaline. Reaction alkaline. 

The total solids are hardly two-thirds of the amount in woman's milk. 
The fat especially is greatly deficient, being only about one-sixth of the 
amount in woman's milk, and the proteids are but two-fifths of the amount 
in woman's milk. 

A dilution of 1 part of good cows' milk with about 7 parts of water will 
contain about the same amount of milk as milkine prepared as above. 

Cereal AT ilk. 
Cereal milk is a malted dried milk food. It is stated by its makers to 
be a complete food, cooked and ready for use with the simple addition of 



198 INFANT FEEDING. 

water, and to be made from the purest Vermont dairy milk, the finest 
wheat gluten flour, the best barley malt, and milk-sugar. 

Cereal milk in general appearance very much resembles the other 
malted dried milk foods, but it contains a much greater percentage of milk- 
sugar, showing that this substance is used in its manufacture, as claimed. 

The directions for preparing it for use are to mix 1 teaspoonful of 
cereal milk in a teacupful of hot water for infants under three months of 
age or for a very delicate child. 

Preparation for a child six months old : — 

"To make 6 ounces Prepared Food, use 3% rounding teaspoonfuls Cereal Milk 
Powder," as directed. ^ 

Composition when prepared : — 

Table No. 42. 

Cereal Milk. Woman's Milk. 

Water 90.98 86.73 

Total solids 9.02 13.26 

Fats 0.38 4.13 

Proteids 1.09 2.00 

Inorganic salts 0.21 0.20 

Carbohydrates 7.34 6.93 

The reaction to litmus was neutral, or faintly acid. The food contains 
starch. No white of egg or cream was added, since neither is definitely pre- 
scribed. This fact may be taken into consideration when comparing the 
analysis with that of the other foods. 

The total of soluble carbohydrates as above is practically the same as 
in woman's milk; the amount of proteids is less than one-half the amount 
in woman's milk, and about one-half is insoluble in water. The amount of 
fat is one-eleventh the amount in woman's milk. The small amount of fat 
indicates that the cereal extractives and milk-sugar make up the bulk of the 
solids of this food, and that a dilution of 1 part of good cows' milk with 11 
parts of water would be the counterpart of the above mixture as to the 
amount of milk therein. 

Wampole's Milk Food. 

Wampole's milk food is a malted dried milk food. Its makers state 
that it is made from malted cereals, beef, and milk, and when mixed with 
warm water it is immediately ready for use; no other preparation neces- 
sary. 

This dried milk food is very nearly soluble in water, owing to the solu- 
ble carbohydrates being so large a constituent. A little less than one-half 
of the proteids is insoluble in water. A small amount of beef extract has 
been combined with the cereal extractives and dried milk. 



[MPERIAL GRANUM. I'M) 

To prepare it for an infant 6 months to 1 year of acre the directions 
are to dissolve -A to 6 teaspoonfuls of the food in 6 ounces of hot water. Com- 
position when prepared by dissolving 6 teaspoonfuls in 6 ounces of water: — 

Table No. 43. 

Wampole's Milk-food. Woman'* Milk. 

Water B8.59 88.51 

Salts 0.46 0.34 

Proteids 1.58 2.35 

Fat 0.73 2.41 

Maltose, dextrin, etc 7. 05 

Milk-sugar 0.99 0.39 

Reaction alkaline. Reaction alkaline. 

Compared with woman's milk it is seen that the carbohydrates are 

considerably in excess, and the proteids and fat are deficient, the fat espe- 
cially, it being less than one-third the amount in woman's milk. 

One part of good cows* milk diluted with about o 1 ^ parts of water 
would be analogous to the dilution of milk in WampOle's milk food pre- 
pared as above. 

Imperial Graxoi. 

Imperial granum is a farinaceous food to be used as an adjunct to cows' 
milk. 

It- makers state that it is a solid extract derived from very superior 
growths of wheat, nothing more. It appears to be made as claimed from 
wheaten floor and to be mainly composed of torrefied starch. 

For an infant six months of age it is to be prepared by cooking sy 2 
teaspoonfuls of food in 81 ounces of water and 20 ounces of milk. 

Composition when prepared as above : — 

Table Xo. 44. 

Imperial Granum. 1 Woman's Milk. 

Water 91.53 88.51 

Salts 0.34 0.34 

Proteids 2.15 2.35 

Fat : 1.54 2.41 

Starch 1.22 

Maltose, dextrin, etc 0.58 

Milk-sugar 2.71 6.39 

Reaction alkaline. Reaction alkaline. 

The total of solids contained is one-qnarter less than in woman's milk; 
the carbohydrates are nearly one-third less than the amount in woman's 
milk, and it should be observed that 1.22 per cent., or about one-fourth of 
them, consist of starch: there is only a slight deficiency in the amount of 

1 According to Chittenden. 



200 INFANT FEEDING. 

proteids, but a considerable deficiency in the amount of fat. By using more 
milk or milk and cream and less water than above employed the percentages 
of fat, proteids, and soluble carbohydrates would be increased. 

Its very large proportion of starch forms the principal objection to this 
food. 

The presence of unconverted starch causes the thick condition of the 
mixture. 

Eskay's Albumenized Food. 1 

This food is to be prepared with cows' milk. Its makers state, in rec- 
ommending their product, that it contains the more easily digested cereals, 
combined with egg albumin. 

Eskay's albumenized food consists largely (about 88 per cent.) of car- 
bohydrates; the soluble carbohydrates, mostly milk-sugar, are about 50 per 
cent., and the insoluble carbohydrates, mostly starch, are a little less than 
40 per cent. On account of this proportion of starchy matter in the dry 
food, it may be termed farinaceous. The makers, however, claim that in 
the process of manufacture the starch granules are almost entirely disin- 
tegrated, and when the food is prepared with milk according to directions 
the percentage is said to be not over 1% to 2 per cent. An analysis of the 
dry food shows that it contains about 9 per cent, of proteid matter, but 
when prepared according to the six months' formula it analyzes about 2.55 
per cent. 

The fats as well as the proteids are almost entirely vegetable, with a 
small percentage of each derived from eggs. Excepting the egg, fat, and 
albumin, the preparation is produced from wheat, oats, and barley, and, while 
no proteolytic ferments are used in its manufacture, the insoluble carbo- 
hydrates are nevertheless partially converted into dextrin by a special 
process of heating, which ruptures the starch granules and converts a small 
amount of the starch. 

The egg albumin is said to be first combined with sugar of milk in 
such a thorough manner that the particles are finely subdivided, and no 
firm, hard coagulum can therefore take place in the stomach. The particles 
retain their identity, and do not coalesce; so that in the finished prepara- 
tion the egg albumin is suspended throughout the whole mixture in very 
fine particles, which are easily digested, because the gastric juice acts by 
contact, and, the smaller the particles, the greater the effect of the gastric 
juice. No claims are made by the manufacturers for its solubility, but for 
its ease of digestion and its nutritive value. 



1 The chemical analyses of Eskay's food, Mellin's food, cereal milk, and malted 
milk here given were specially made for me by Professor Lafayette B. Mendel, at the 
Sheffield Laboratory of Physiological Chemistry, Yale University. 






ES KAY'S FOOD. 201 

The directions for preparing it for an infant six months of age are to 
take:— 

Eskay's food 5 tablespoonfuls 

Hot water 1 pint 

Rich cows' milk 2 pints 

As directed. 

Composition when prepared as above: — 

Table No. 45. 

Eskay's Food. Woman's Mil\. 

Water 84.4b" 86.73 

Total solids 15.54 13.2G 

Fats 3.07. 4.13 

Proteids 2.78 2.00 

Inorganic salts 0.58 0.20 

Carbohydrates 9.11 6.93 

The reaction to litmus was amphoteric. 

The food contains a noticeable quantity of starch which is in the form 
of a thin paste in which all the grains are ruptured by the process of prepa- 
ration. The boiling was carried on for fifteen minutes in the sample an- 
alyzed. 

Kich milk (4.85 per cent, of fat) was used as specifically directed. 

Mellin's Food. 

Mellin's food is a malted cereal. This food is stated by its makers to 
be a soluble dry extract from wheat and malt, for the modification of fresh 
cows 7 milk. 

The carbohydrates therein are in the form of dextrin and maltose, and 
constitute about 80 per cent, of the food; the proteids amount to about 
10 per cent, and are derived from the cereals. Mellin's food is almost com- 
pletely soluble in water. It is especially noticeable that this food does not 
contain any starch. 

The directions for preparing this food for use for infants six months 
of age and over are to dissolve. 2 heaping tablespoonfuls of food in }£ pint 
of hot water and % pint of cows' milk. 

Composition when prepared as above : — 

Table Xo. 46. 

M 'ell in's Food. Woman's Milk. 

Water 85.37 86.73 

Total solids 14.63 13.26 

Fats 3.16 4.13 

Proteids 3.03 2.00 

Inorganic salts 0.70 0.20 

Carbohydrates 7.74 6.93 



202 



INFANT FEEDING. 



The reaction to litmus was amphoteric. The food gave no reaction for 
starch. Milk having 4.25 per cent, of fat was used in this preparation,. 

In total solids this food differs but slightly from woman's milk, and in 
the various constituents its similitude to woman's milk is remarkably close. 
Of the carbohydrates the maltose and dextrin are a little less in amount 
than the milk-sugar, and the total carbohydrates (7.74 per cent.) are greater 
than the amount in woman's milk. 

The manufacturers of Mellin's food present many formulas for pre- 
paring the food for use to meet various indications. The following for- 
mulas are given with the analyses of the respective milk modifications : — 

Table No. 47. 

Formula and Analyses foe Preparing Mellin's Food. 

For Infants About Tico Months Old. 

Water 
Mellin's food, 6 teaspoonfuls 

(level). | Gives this 

Milk, 6% fluidounces. f composition 

Water, 9% fluidounces. 



J 



93.40 

Salts 0.35 

Proteids 1.69 

Fat 1.53 

Carbohydrates (no 

starch) 3.03 



Mellin's food, 2 tablespoonfuls 

(heaping) . 
Cream, 1% tablespoonfuls. 
Milk, 4 fluidounces. 
Water, 12 fluidounces. 



Low Proteids. 



Gives this 
composition 



Water 91.50 

Salts 0.37 

Proteids 1.45 

Fat 2.50 

Carbohydrates (no 

starch) 4.18 



High Fat and Low Proteids. 



Mellin's food, 3 tablespoonful 

(heaping) . 
Milk, 4 fluidounces. 
Cream, 2 tablespoonfuls. 
Water, 12 fluidounces. 



'l 
1 



Gives this 
composition : 



Water 89.36 

Salts 0.45 

Proteids 1.65 

Fat 3.00 

Carbohyd rates (no 

starch) 5.54 



Just's Food. 

Maltose, free 12 

Maltose, combined with dextrin as maltodextrin 15 

Dextrin, with trace soluble starch 61 

Albuminoids 1 

Fat 



'at 

Ash 

Water 

Cellulose 

Indeterminable ( insoluble ) 



.6 parts 
,5 parts 
.3 parts 
.1 parts 
.1 part 
.9 part 
.3 parts 
.2 part 
.0 parts 



100.0 parts 



PEPTOGENIC MILK POWDER. 20:5 

This sample was neutral in reaction; the sample was analyzed June 
14, 1895; was slightly acid, which suggests that the process of manufac- 
ture has been changed a little. The food has no diastasic action. 

The small amount of albuminoids, light color of the food, and the low 
degree of conversion, particularly of the last sample analyzed, indicate very 
conclusively that no considerable quantity of malt or any entire cereal is 
used in its manufacture. It is not hygroscopic — it can be exposed to air 
for quite a long time without becoming sticky. 

Upon examination, the above analysis indicates a close relation of Just's 
Food to commercial glucose, although it contains no dextrose. 

A product similar to Just's might be obtained from the glucose process 
if the process were stopped early in the conversion before the starch was 
converted to glucose; that is, when the conversion of the starch has pro- 
gressed only as far as dextrin and maltose; or it might be possible, during 
the process of making glucose, to draw off a portion in the earlier stages 
of the process, and neutralize and clarify, and obtain a product similar to 
Just's food. 

In order to get such a percentage, as is given in the analysis of dextrin 
and maltose, from a starch material by the action of malt diastase, it would 
be necessary to use so much malt that the amount of albuminoids contained 
would be much larger than is shown by the analysis, and the product would 
have a decided malt flavor and quite a marked color, and these Just's food 
has not. 

Peptogenio Milk Powder. 

This product is stated by its makers to be an article containing milk 
sugar and a digestive ferment capable of acting on casein, offered for the 
preparation of an artificial infant food. McGill states: "It is not, in the 
strict sense, a food. Its professed object is so to change the composition 
of cows' milk as to render this comparable to human milk. This it seeks 
to do by introducing milk sugar and small quantities of albuminoids." Ac- 
cording to McGilPs analysis, it is composed almost entirely of milk sugar 
( ( J6. 60 per cent.). 

The following analysis is by Leeds, and is taken from a circular of the 
makers. 

Composition of "humanized milk" prepared as directed, using 4 meas- 
ures of peptogenic milk powder with 1 / 2 pint of milk, 1 / 2 pint of water, 
and 4 tablespoonfuls of cream : — 

Table No. 48. 

Humanized Milk. Woman's Milk. 

Water 80.20 88.51 

Ash 0.30 0.34 

Proteids 2.00 2.35 

Fat 4.50 2.41 

Milk-sugar 7.00 6.39 

Reaction alkaline. Reaction alkaline. 



204 



INFANT FEEDING. 



Chittenden's analysis of this "humanized milk*' is almost identical with 
the above. 

The proteids of the cows' milk undergo a change in the peptonizing 
process, being converted chiefly into partial peptones, and in this form they 
cannot be said to resemble the proteids of woman's milk, which have not 
been acted upon by a proteolytic ferment. 

Table No. 49. — Summary Giving Comparison of the Foods Analyzed by Professor Mendel. 





Cereal Milk. 


Malted Milk. 


Mellin's Milk. 


Esk^y-g Milk. 


Human Milk. 


Water 

Total solids .... 


90. OS 
9.02 


90.74 
9.20 


85.^7 
14.63 


84.86 
15 54 


B6.73 
13.26 


Fats 

Proteids .... 
Inorganic salts . 
Carbohydrates . 


0.38 

1.09 
0.21 

7.34 


0.63 

1.65 
0.36 
6.62 


5.16 
3.03 

0.7 ] 

7.74 


3.0fl 

2.7S 
0.5S 
9.11 


4.13 

0.20 

6.93 


Reaction to litmus 


neutral 


alkaline 


amphoteric 


amphoteric 





(The figures indicate percentages by -weight,) 



The figures quoted for human mi'k are well-known averages ; it would 
be more accurate to give figures indicating the healthy variations. 



Table No. 50. 

Composition of some Infant Foods as Prepared for the Nursing Bottle in Comparison xcit\ 
Mother's Milk. Prepared According to Directions for If ants of Six Months. 1 





Mx : her^s 


Malted 


>"-?s::e"s 


Imperial 


Me:iin's 


Pertogenic 

Mi k 

Powder. 




Milk. 


Milk, 


Milk Food. 


Gr.-.num. 


Food, 


Special Gravitv 


1031 


1025 


1024 


1025 


1031 


1039 


V\'ater 


86.73 


92.47 


92.76 


91.53 


Ba i 


86.03 


Total solid matter . . • 


13.26 


7.43 


7.24 


8.47 




13.97 


Inorganic salts . . 


0.20 


0.29 


0.13 


0.34 


0.47 


0.26 


Total albnminoids . . 


2.00 


1.15 


0.81 


2.15 


2.62 


3.09 


Soluble albuminoids . 


2.00 


1.15 


0.36 


1.67 


2.62 


2.09 


Insoluble albuminoids 





trace 


0.45 


0.^8 








Fat . 


4.13 


0.68 


0.36 


1.54 


2.89 


4.3S 


Milk sugar ..... 


6.93 


1.18 


0.84 


2.71 


3.25 


7.26 


Cane sugar 








2.57 











Maltose 





3.28 


trace 


trace 


2.24 





Dextrin 





92 


0.44 


0.58 


0.53 





Soluble Starch .... 


















Starch 








1.99 


1.22 








Reaction 


alkaline 


alkaline 


alka'.ine 


alkaline 


alkaline 


alkaline 



'Copied from an article in the New York Medical Journal, July IS, ISVo, by S. H. Chittenden, Ph. D. 



CHAPTEK VII. 
i ONCENTRATED PREPARATIONS OF ALBUMIN. 
Among the concentrated preparations of albumin on the market are: — 

SOMATOSE. 

Somatome, meat albumin, isolated artificially by chemical process. A 
remedy which has more the character of a pharmaceutical preparation of 
a stimulant tonic, rather than of a food. This is evident also in its cost. 
It is used extensively and with good result-. It is advisable to be cautious 
with the same owing to the diarrhceal tendency. It should, therefore, not 
be given to very young infants. 

Chemical analysis : — 

Water 11.41 parts 

Digestible albumin 41.21 parts 

Peptone 27.12 parts 

Otber niti - og?nous substances estimated by difference 
and assumed to consist of meat basis and ex- 
tractives 14.51 parts 

Asb 5.75 parts 

100.00 parts 

Somatose is stated to be prepared from meat. It is a light-yellow pow- 
der, odorless, nearly tasteless, and readily and completely soluble in water. 
The solution has a slightly alkaline reaction. 

The substance is a predigested, nitrogenous food. 

It is probably made from animal substances, but we are unable to 
state from what materials or by what process the article is manufactured. 
It- contents of phosphoric acid and potassium are very much less than 
should be the case if it were prepared from muscular tissue, or meat in the 
usual sense of the term. 

Er ca six. 

Eucasin is an ammoniated salt of casein. A soluble preparation of 
casein, obtained by chemical process. It contains phosphorus. 0.8 and 13.1 
per cent, of nitrogen. It is well tolerated by older children, but does not 
prove very satisfactory in very young infants. 



A UTROL. 

Nutrol is the sodium compound of casein; also soluble. 



(-203) 



206 INFANT FEEDING. 



Tropon". 

Tropon is a mixture of animal and vegetable albumin. Obtained chiefly 
from buckwheat flour by dissolving with dilute caustic soda, precipitating 
with acid, and purifying with hydrogen peroxide. It was introduced by 
Finkler (Berlin. Min. Wochen., 1897, Nos. 30, 33). Also sano-tropon, 
which is really a mixture of dextrinized barley flour with tropon. Sana- 
togen is very similar to the latter preparation, and consists of casein with 
glycerophosphate of sodium, and 13 per cent, nitrogen. 

Plasmon". 

Plasmon is a preparation of casein, partly soluble. Obtained by chem- 
ical process, the use of carbonic acid and bicarbonate of soda. It is adapted 
for the strengthening of ordinary broths, but it must be distinctly remem- 
bered that all of these preparations are merely suggestions as "substitutes," 
and should never be thought of as suitable for constant feeding. 

Soson. 

Soson is a new albuminous product resembling plasmon and tropon 
in nutritive qualities. 

Other foods are Sanose-Albumose (Schering) ; also Sanatogen, TUvr 
lactol, Protogen (Blum), and the Somatose Cream Mixture of the Elber- 
feld Farbenwerke. 

All of the above preparations have been used by the author in doses of 
y 2 teaspoonful added to either barley soup, chicken broth, farina, or rice 
gruel. 

When typhoid fever and such disorders tax the ability of the attend- 
ing physician, owing to the rejection of food, then, and then only, should 
milk or its dilution be laid aside and the above foods given a trial. . Valu- 
able service has been frequently given by such standard preparations as 
panopepton, liquid peptonoids, and Mosquera's beef jelly where the gastric 
irritability prevents the regular administration of milk. 

Mosquera's Beef Meal. 

This is a partially digested beef preparation, containing in addition 
to the proteids 13.06 per cent, of fat. 
The analysis is : — 

Water G.68 

Salts and inorganic substances 4.20 

Fats . . 13.06 

Insoluble proteids 47.61 

Albumose 29.43 



ALBUMINOUS FOODS. 207 

Taking the insoluble proteids, albumose and fats, together, 100 grams 
are equal to L35 calories, while the albumose alone represents L22 calories. 



MokockkaV Beef Jelly. 

This beef jelly contains 12.66 per cent, of albumose and 14.35 per cent. 
meat extractives. It represents therefore the stimulant as well as the nu- 
trient qualities of beef. 

A two-ounce jar is equal to 34 calories from the albumose, and if we 
were to take the meat extractives at the same ratio the total number of 
calories would be 94. 

Panopepton. 

Panopepton represents the products of the peptic digestion of fresh, 
lean beef, and of the proteolytic and amylolytic digestion of whole wheat; 
proteids in the form of albumose and peptone, carbohydrates as achrbo- 
(1 ex trins and maltose, and the natively associated soluble, savory, and 
stimulant mineral constituents. These soluble food constituents are ster- 
ilized, concentrated, and, after being duly proportioned, are redissolved in 
sherry wine. 

Panopepton contains 20 per cent, of solids as follows: — 

Soluble proteids 6 per cent. 

Carbohydrates 13 per cent. 

Ash 1 per cent. 

It will be noted that the ratio of proteids and carbohydrates is as 1 to 
2.16, which is best calculated for a proper nutritive balance. Harrington's 
analysis shows that it yields 17.99 per cent, of solid matter (including 0.97 
per cent, of mineral matter) and 18.95 per cent, by volume of alcohol. 

This is undoubtedly one of the best predigested foods of the class that 
contains both proteids and carbohydrates in their most available forms, and, 
from the data supplied by its manufacturers, it is evident that it is designed 
upon scientific principles to represent the varied constituents of a mixed 
diet, and that its preparation is carried out in a most perfect manner in all 
respects. The wine serves both as a stimulant and preservative, and the 
product has an agreeable taste and flavor. One hundred grams (about 3 a / 3 
ounces) equal 77.5 calories. 

It must not be taken for granted that because one chemist finds a very 
high percentage of alcohol in a standard preparation the same amount 
will be found by other chemists; for instance, the preparation of "liquid 
peptonoids," made by the Arlington Chemical Co., was sent to Dr. Ernst J. 
Lederle. This chemist found 17.59 per cent, alcohol by volume. 



208 INFANT FEEDING. 

Table No. 51.— Chemical Analyses by Dr. Ernst J. Lederle and 
J. A. Degliuee, Ph.D. 

An interesting comparison as to the alcohol content can be made by studying 
the analyses of the six nutritive tonics submitted for examination; they are: — 

Nutritive Liquid Peptone 23.49 per cent, alcohol by volume 

(Parke, Davis & Co.) 
Liquid Peptonoids 17.59 per cent, alcohol by volume 

(Arlington Chemical Co.) 
Mulford's Pre-Digested Beef . . . 19.39 per cent, alcohol by volume 

(H. K. Mulford & Co.) 
Tonic Beef 17.04 per cent, alcohol by volume 

(Sharp & Dohme) 
Trophonine 18.98 per cent, alcohol by volume 

(Reed & Camriek) 
Panopepton 20.05 per cent, alcohol by volume 

(Fairchild Bros. & Foster) 



CHAPTER VIII. 



ADDITIONAL NUTRIENTS AND STIMULANTS. 



Meigs's Food. 

Meigs's food consists of milk, cream, sugar, gelatine, and arrowroot, 
and is prepared as follows : Of Russian gelatine or isinglass, 20 grains, or a 
piece about two inches square, is soaked for a few minutes in cold water, 
and then boiled in half a pint of water for fifteen minutes, or until com- 
pletely dissolved. One teaspoonful of arrowroot is mixed to a paste with 
cold water, and then added to water to make half a pint. This is now added 
to the gelatine solution, as is also, with constant stirring, the desired quan- 
tity of milk; just before removing from the fire the cream is added. The 
amount of milk and cream used should vary with the age of the infant. 
For an infant under one month, 4 ounces of milk and 1 1 / 2 ounces of cream 
are to be used ; for those older the milk is gradually increased to 16 ounces 
and the cream to 2 ounces. 1 

Zoolak. 

The subjoined analysis of Dr. Dadirrian's zoolak was made by Edgar 
E. Wright, of Brooklyn, N. Y. 

In every 100 parts of zoolak there are: — 

Water 87.69 

Proteid substances 3.98 

Fat 4.91 

Milk-sugar 2.03 

Alcohol 0.07 

Ash or mineral salts 0.78 

Lactic acid 0.50 

Carbon di-oxide 0.04 

This analysis shows that in the production of zoolak but little change 
is wrought in the percentage composition of the original cows' milk, save 
what would naturally be produced by the fermenting and peptonizing actions 
of the kefir ferment. 

These fermentative changes — primary and secondary — consist in : — - 

1. The transmutation of a portion of the natural milk sugar into 
alcohol, lactic acid, and carbon dioxide. 

2. The transmutation of a certain percentage of the proteid sub- 
stances into protoses, and finally, perhaps, into true diffusible peptones. 

1 Meigs and Pepper: "Diseases of Children," 1887. 

(209) 



210 INFANT FEEDING. 

This latter action, however, does not change the percentage presence of the 
proteid bodies, as related to the total quantity of milk, but simply changes 
their chemical form. 

Jurock's kefir-ferment-pastilles, recently introduced in our country, 1 are 
a very rapid and practical method of making kumyss. These tablets will 
keep indefinitely and can therefore be utilized wherever fresh milk can be 
obtained. Its nutritive value has been well established, in adults as well 
as children. 

The Nutritive Value oe Eggs. 

It is commonly asserted that an egg contains as much food value as a 
half-pound of meat. This is not true. While there is an approximate 
equivalent between the albuminoids contained in both, the egg contains no 
carbohydrates. Very young infants do not digest eggs, and frequently gas- 
tric disturbances result from their use. This does not necessarily imply 
that the white of egg in its raw state should never be used as an adjunct to 
other forms of feeding, or as a temporary food when milk disagrees or when 
diarrhoeal conditions, such as fermentative and catarrhal intestinal dis- 
eases, prohibit the use of milk. 

Lecithin. 

Lecithin is a crystallizable fat of a peculiar nature containing nitrogen 
and phosphorus. It is unstable. When chemically treated by neurin and 
glycerine phosphoric acid can be isolated. Lecithin has also been found in 
the yolk of egg, in the egg of fish, etc. Hoppe-Seyler isolated this sub- 
stance in 1870 from its constant association with phosphorized albumins, 
nucleo-albumin, and nucleo-proteid. Lecithin is also found in the brain 
matter. 

Free lecithin has been used clinically and physiologically by Danilewski 
in 1895. According to this physiologist, animals fed with lecithin grew 
more rapidly than those not fed on this substance. It is a reconstructive 
and is indicated in the treatment of all disorders of nutrition. My experi- 
ence with lecithin has been limited to rachitis, tuberculosis, and cases in 
which atrophy due to malnutrition is found, such as result from pertussis. 
I am also using it in cases of sporadic cretinism. 

A preparation of lecithin containing one grain of pure lecithin to the 
drachm is made by Fairchild Bros. & Foster, of New York City. A tea- 
spoonful of this solution given three times a day before meals has given me 
very good results. 

Lecithin of the Egg. — According to Coloumbe, lecithin exists in all 
the tissues, especially in those endowed with great vitality. From a thera- 
peutic point of view it is not toxic, and it is assimilated as a whole in 
ordinary doses. Its action consists in increasing the number of red cor- 



By Dr. L. Amster. 



COCOA. 



211 



puscles; in increasing, in certain cases ai Least, haemoglobin ; in increasing 
urea and diminishing uric acid, and in stimulating the appetite. Its em- 
ploymenl is indicated m anaemia, in all troubles of nutrition, in wasting dis- 
eases, and in neurasthenia. It may be administered hypodermically or by 
the mouth. 

Steak Juice or Meat Juice. 

The juice of broiled steak possesses anti-scorbutic properties. I have 
referred to this in the chapter on scurvy. When dentition is delayed or 
when the bony structure is weak, as in rickets, steak juice should be freely 
given. It is best prepared fresh each day. For this purpose a meat press 
(see illustration) is convenient. When fresh steak juice cannot he obtained, 
then Valentine's meat juice can be tried. For the treatment of scurvy fresh 
meat juice must be used. 




Fi£. 53. 



The Use of Cocoa ix Ciiildrex. 

The value of cocoa as an infant food is underestimated, although a 
great many preparations of cocoa on the market are useless. 

Indications. — When there is a tendency to diarrhoea and in general 
marasmic conditions, the nutritious effect of cocoa, should be remembered. 
I frequently add one or two teaspoonfuls of cocoa to modify the curd in 
milk in the same manner as I prescribe some of the infant foods. During 
convalescence following the acute infectious diseases, especially diphtheria 
and scarlet fever, cocoa should be given. In pulmonary catarrh and in 
tuberculous manifestations, the use of cocoa is indicated. If milk is not 
well borne I frequently add one or two teaspoonfuls of cocoa properly 
sweetened to rice water. 

H. Cohn, 1 in describing the chemical value of cocoa as nourishment, 
states his belief that it is overrated, and denies the value of the same. He 



1 Zeitsehrift f fir physiologisclie Chemie, xx, 1. 2. 



212 INFANT FEEDIXG. 

bases his statement on the poor method of assimilation, owing to the large 
quantity of fat which could be removed by chemical process. Cocoa also 
contains 5.5 per cent, of tannic acid. Besides, the albuminoids are con- 
verted, by the process of roasting, into a very indigestible product. About 
the tannic acid, he says that it precipitates the digestive ferments, and unites 
with the albuminoids into insoluble compounds, causing the constipating 
factor. According to his experiments, only one-half of the 16.6 per cent. 
of the albuminoids are absorbed, and. in order to give the human body 
enough cocoa to have a sufficient quantity of proteids, it would be neces- 
sary to feed at least somewhat over 2 pounds daily, provided cocoa alone 
was given for nourishment. 

A cocoa is found on the market in which a large percentage of oil has 
been extracted. This renders it more easily digested. 1 

Chocolate. 

Chocolate contains about 45 per cent, of cane-sugar, but no dextrose 
or la?vulose. The remainder consists of cocoa powder. Invert sugar, or a 
mixture of glucose and albumin, is largely used in the preparation of un- 
crystallized sweets, such as the creamy matter in the interior of chocolate 
drops. The coloring of sweets is derived either from burnt sugar or from 
one of the aniline dyes, most commonly eosin. Cochineal is also a favorite 
colorer. It is interesting to know that these dyes may be excreted in the 
urine almost unchanged, and cases are on record where patients were sup- 
posed to be passing blood when they had merely been sucking red sweets. 
There is no reason to suppose, however, that such substances are harmful 
to life. 2 When there is a tendency to loose bowels, especially after the 
second summer, cocoa and chocolate should be added to the dietary. It is 
to be added to milk and thoroughly boiled. One cocoa feeding per clay is 
usually enough. One teaspoonful of cocoa to a cup of milk, the latter to 
be thoroughly boiled, is the usual quantity used. Several formula? for 
making chocolate will be found in the "Dietary." 

ICE-CREA^I AXD WATER-ICES. 

Ice-cream and water-ices are very grateful to a feverish child. When 
milk and cream are refused they will be greedily taken. These prepara- 
tions will alleviate the pain on swallowing in the case of diphtheria. They 
contain considerable nourishment, but must be given in moderation. Nau- 
sea and vomiting may frequently be controlled by them. 



1 This cocoa is manufactured by Croft & Allen, of Philadelphia. It is put up 
in glass jars. 

- Hutchison, "Food and Dietetics/' page 26o. 



COFFI-R. 



21 



The Use of Coffee in Children. 1 



Contraindications. — When giving coilee to children we must bear in 
mind that: — 

First. — Coffee is in no sense a food, because it can neither build up 
the tissues nor provide them with potential energy. 

Second. — Coffee perhaps acts the part of a lubricant to the machinery 
of the body, and exerts its stimulating influence by toning up and dimin- 
ishing nervous fatigue in adults, and is not called for in children. 

Third. — Coffee produces a disturbance of digestion due to a direct 
interference with the chemical part of the process, but in part also indi- 
rectly brought about by the nervous system; it also produces a dyspepsia 
which is of the atonic type, and a slow digestion, accompanied by flatu- 
lence, with a disturbance of the heart's action, so that it is decidedly con- 
traindicated from a feeding standpoint. 

Coffee is a cardiac stimulant, quickening the heart's action in small 
closes, and depressing it in large quantities. 

It certainly disturbs the cardiac rhythm when taken in excessive doses 
by children. Such symptoms are muscular tremor, nervous anxiety, and 
dread of impending danger, as well as palpitation; cardiac intermissions, 
and an uncomfortable feeling referred to the cardiac region can be traced 
to coffee, according to Yeo; it is a diuretic, and increases the excretion of 
area; it produces insomnia, nervousness, and fear; also, choreiform move- 
ments. 

Caffeine has been known to produce paralysis in the lower animals, 
and might produce a similar effect if taken in large quantities by children. 
It retards digestion, hence it is contraindicated in children. 

Owing to the great tendency to produce insomnia coffee should not be 
administered in the evening unless the heart's action demands it. 

Indications. — As a cardiac stimulant, or whenever caffeine is indicated, 
hot coffee should be given in small doses, one or several teaspoon fuls, re- 
peated every fifteen minutes, until its physiological effect is manifested. 
This can only be noted by studying the pulse. Great care should be exer- 
cised in administering large quantities of coffee to children, or very strong- 
coffee, as in either instance it will produce a marked cardiac depression, 
and also a disturbance of the cardiac rhythm. 

In the convalescence of typhoid fever or pneumonia in children, there 
is no better stimulant than coffee administered in small doses to which 
large quantities of mi'k or cream are added. This is an especially valuable 
dose in the great cardiac depression so frequently noted in the convales- 



1 Paper read by me before New York County Medical Association, December 17, 
1900, '"Acute and Chronic Coffee Poisoning." See Transactions. 



214 INFANT FEEDING. 

cence of diphtheria. (See chapter on "Diphtheria/') The coffee usually 
used consists of the following strength: — 

Coffee 2 ounces 

Water . 1 pint 

When an infusion of the above strength is made, Hutchison found 
that each teacupful of coffee contained: — 

Caffeine 1.7 grains ; and also 

Tannic acid 3.24 grains 

The latter in the form of gallo-tannic acid; so that judging from this 
analysis, coffee should be made much weaker (one ounce to a pint of water), 
and should be administered in teaspoonful doses. 

For fuller details on "Physiological Effect of Coffee," read paper and 
discussion at the New York County Medical Association, 1900, by Leszyn- 
sky, Fischer, and others. 

The Use of Alcohol in Children. 

Alcohol in the form of wine or beer or whisky, in any and every form, 
is not only detrimental to the infantile organism, but will leave permanent 
injury if its use is prolonged. There is a decided difference between the 
continual use of alcohol as a food and its use when indicated as a medicine. 
Physicians know that whisky or wine given to stimulate the weakened heart 
in the course of a fatal attack of pneumonia or diphtheria, is not only 
necessary, but frequently the only means of prolonging life. It can easily 
be seen that if a child lias been brought up and given alcoholic drinks daily 
as an adjuvant to the other articles of food, that in such critical times 
when required to stimulate the heart we must either resort to enormous 
doses to procure a given effect or many times we will fail in producing 
a certain effect which may mean the loss of a precious life. Thus, it be- 
comes necessary to emphasize the importance of abstaining from habitual 
feeding of alcoholic drinks in any form to the young and growing child. 

In a large children's clinic with which I have been associated it was 
very interesting to study the amount of alcohol given to young children, 
and I was surprised to find that more than 50 per cent, of all children from 
six months old and upward regularly received their sip of beer or drop of 
whisky "to strengthen their hearts." The author has frequently attended 
alcoholic dyspepsia due to prolonged use of beer and wine. This is most 
common among the tenement population, where the baby forms part of the 
family at the table, and necessarily partakes of almost everything eatable 
and drinkable along with its parents. 



TEA. 



215 



The Use of Tea in Children 1 . 

In my chapter on the use of coffee, I have already mentioned the 
deleterious effect of coffee on the growing infant or child ; what has been 
said there regarding coffee applies equally strong to the use of tea. The 
nervous system when overstimulated in an infant is far more sensitive than 
the adult. The author has frequently noted that children suffered with 
sleeplessness and were very irritable, simply through the prolonged use of 
such stimulants as tea and coffee. A noteworthy point is that the appetite 
disappears when tea and coffee are given, and reappears when their use is 
interdicted. 

It must not be supposed that tea is a poison, and there are times when 
physicians will find it necessary to use small quantities of tea to stimulate 
the body, as for example, in that form of exhaustion following a protracted 
diarrhoea, as is usually the case in summer complaint, so-called cholera 
infantum. 



CHAPTEE IX. 

INFANTS' WEIGHT. 

Whe^t a child develops normally, it gains in weight. Breast-fed 
infants, as a rule, gain more than bottle-fed infants. The progress of an 
infant can be watched by a comparison with its weight. The moment a 
child's weight is stationary, the reason for the same should be ascertained. 




Fig. 54. — The Chatillon Scale is a veiy convenient basket scale. It is very 
useful in the nursery. 



If the baby is breast-fed the milk of the nursing mother should be sent to 
a chemist for examination. (The details have already been described in 
the chapter on "Breast-milk.") 

Disturbances of the mother interfering with proper lactation are at 
once evident in her mi'k. Such disturbances are: (a) menstruation, (b) 
general anaemia, (c) tuberculosis, (d) pregnancy will frequently alter the 
percentages of the ingredients of milk so that a child will not receive 
sufficient nutrition. 
(216) 



WKKillT IX BREAST-FEEDING. 



217 



The first evidence of such malnutrition will be seen on the scales. 
The child will not gain in weight, and frequently it will lose weight. 

How Much Should an Infant Weigh? — The average weight at birth 
is 3 pounds. Some children weigh considerably more and some less. A 
child should double its weight at the end of five months, and treble its 
weight at the end of the first year. It must not be supposed that because 
a child weighs less than this amount that it may not be healthy. All fac- 
tors should be taken into consideration and a child should be carefully 
examined to determine whether or no it is normal. Very many babies are 
up to the normal in weight, and still show marked rachitis. The very fat 
and flabby baby — usually supposed to be extremely healthy by the laity — 
is the one in whom physicians most frequently meet with constitutional 
disorders. Thus, too much stress should not be put on the scales, for we 
know that they have their limitations. In the beginning, or during the first 
and second months, a normal infant gains about 6 to 8 ounces a week. Dur- 
ing the third month a child gains from 4 to 6 ounces per week, and after the 
third month from 3 to 4 ounces per week. 

Weighing Immediately After Nursing to Determine the Quantity of 
Milk an Infant has Taken. — When scanty milk supply is suspected in either 
the nursing mother or in a wet-nurse, then we can, in some instances, resort 
to weighing immediately after the baby has nursed. It is understood that 
the child must be weighed both immediately before nursing and then imme- 
diately after nursing. The difference in weight is the amount of milk 
swallowed. 

While this may serve in some cases, the author has not found it very 
practical, and cannot recommend it, excepting in rare instances. 

It is well known that an infant whose stomach is filled requires rest 
after nursing, and the less it is handled the less is the chance for expelling 
its food. Thus, my advice is not to handle or fumble with a child after 
nursing, but rather aid Xature in resting an infant than provoke vomiting 
by unnecessary handling. 

Table No. 52. 
Table Showing the (rain of a Healthy Infant Fed at tlie Breast. 



Normal weight at birth, 7 

lb. 
Weight when 2 weeks old, 7 

lb. 6 oz. 



Gain at the end of the first 

week, none. 
Gain at the end of 2 weeks, 6 

oz. 



Weight when 3 weeks old, 7 Gain at the end of 3 weeks, 8 

lb. 14 oz. oz. 

Weight when 4 weeks old, 8 Gain at the end of 4 weeks, 8 

lb. 6 oz. oz. 



218 



INFANT FEEDING. 



The following cases will serve to illustrate the weight of infants with 
various methods of feeding — (a) breast-feeding, (&) home modification. 
( c ) laboratory feeding : — 



fl&£ IN WEEKS 




Fig. 55. i Original. 



Baby Robert M. F. Normal at birth. Was wet-nursed. Gain, first month. 
2 1 ! pounds; second month. ll% fi pound-: third month. 1% pounds: fourth month. 
1% pounds. Stools were normal. Had gastric disturbances and symptoms of 
colic while the wet-nurse menstruated. When the child was about seven months 
old the chemical analysis of the breast-milk showed a deficiency of fat and quite a 
high percentage of proteids. The milk supply gradually gave out and it was 
necessary to wean the child. 



\\ EIGHT IN ARTIFICIAL FEEDIN( 



^tW\»^ 



219 



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Baby J. S. Born prematurely. Weighed -5 pounds 14 ounces at birth. Was 
bottle-fed. Vomited, had dyspeptic symptoms, such as cheesy stools, restlessness 
at niglit, crying continually, and excoriated anus. When one month old the Aveight, 
including shirt and diaper, Mas pounds. A wet-nurse was procured. The child 
gained 1 pound during the first week, and an average of 10 ounces a week thereafter. 
Dyspeptic symptoms disappeared; stools became normal. The child was not seen for 
six montbs. and i> a perfectly healthy baby today. 



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Fig. 57. (Original.) 



From baby fed on Eskay's food since end of third week. General condition 
satisfactory, although somewhat constipated. 



220 



INFANT FEEDING. 



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Fig. 58. (Original.) 



Baby A. Case of chronic dyspepsia. Child four months old, weighed 8 pounds 
15 ounces. Gained 13 ounces the first week of treatment; 6 ounces the second week; 
7, 12, 9 ounces respectively during each of the succeeding weeks. The food ordered 
and details of this interesting case on page 175. 



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Fig. 59. (Original.) 



Baby D. S. Weighed 5 pounds at birth. Was fed at Walker-Gordon Labora- 
tory since six weeks old. Lost weight during an attack of measles when twenty-six 



WEIGHT IN LABORATORY FEEDING. 221 

weeks old. Did not gain one ounce from the thirty-eighth to the forty-second week, 
although received a formula of : — 

Fat 4.00 

Sugar 6.50 

Proteids 2.50 

Six feedings, of seven ounces each. 

I ordered the following home modification : — 

Raw milk 6 ounces 

Barley water 2 ounces 

Mellin's food 2 teaspoonfuls 

Feed every three hours. 

In addition thereto I ordered one ounce of steak juice or one ounce of 
orange juice, daily one hour before feeding. 

I also gave the white of one raw egg with the evening feeding. The 
food agreed very well and child gained in weight as 1 gradually added more 
milk and reduced the quantity of barley water. 

A growing child needs far more food than its weight alone would 
indicate, for its income must exceed its expenditure so that it may grow. 
An infant for the first seven months or first one-half year of life should 
have nothing but milk. Up to this age vegetable food is unsuited to it; 
it is purely a carnivorous animal. 

The diet of the infant is nearly twice as rich in proteids, half as rich 
again in fats, and a little more than half as rich in carbohydrates as that 
of the adult. It is, therefore, in a physiologic sense a luxurious diet. 

The strain of growth falls heavier upon the more precious proteids than 
upon the more cheap and common carbohydrates. 1 

When children do not gain in weight, the quantity of sugar should 
be increased. This should be done continuously and with due consideration 
for the other ingredients. 

The constructive ingredient in an infant's food is the proteids. We 
must, therefore, consider this element when an infant's weight is stationary. 

Individual conditions must be considered, and chronic disorders elim- 
inated, e.g., dyspeptic conditions or tuberculosis, before arriving at a diag- 
nosis of what really causes an infant's loss in weight. 

^'Stewart's Physiology," p. 412, 1897. 



PART IV. 

DISEASES OP THE MOUTH, (ESOPHAGUS, STOMACH, 

INTESTINES, AND RECTUM, AND DISEASES 

ASSOCIATED WITH IMPROPER NUTRITION 



CHAPTEE I. 

DISEASES OF THE MOUTH. 

Stomatitis. 

An infection existing on the tonsils or in the pharynx can spread to 
the mouth. Food, especially milk, is sometimes the means of directly con- 
veying poison • this is especially true when milk contains pathogenic bac- 
teria. As I have frequently stated that syphilis and rickets undermine the 
system, so also we find these conditions frequently as predisposing causes. 
The mouth is particularly liable to local infection. The slightest trauma- 
tism by diseased teeth, especially in acute cases, can produce local irritation. 
Non-pathogenic bacteria are always present in the buccal cavity under nor- 
mal conditions. 

"The glands of the mouth being excretory frequently produce inflam- 
matory conditions by virtue of systemic poison excreted by them which 
may produce local lesions." One of the best writers on this subject is 
Forchheimer, whose classification I have adopted : I. Stomatitis Catar- 
rhalis. II. Stomatitis Aphthosa. III. Stomatitis Mycosa, IV. Stomatitis 
Ulcerosa. V. Stomatitis Gangrenosa. VI. Stomatitis Crouposa; Stoma- 
titis Diphtheritica. VII. Stomatitis Syphilitica. 

Stomatitis Cataekhalis. 

Simple stomatitis may be confined to a local area or it may be general. 
When the mucous membrane is irritated by severe rubbing, as during mouth 
cleaning, this condition frequently follows. Dentition does not produce 
stomatitis. This catarrhal form is usually one of the earliest manifesta- 
tions of acute infectious diseases. Great stress is laid on this condition 
as a diagnostic point in measles prior to or associated with the enanthem 
on the buccal mucous membrane. When a small area is affected, a local 
cause, such as a diseased or sharp tooth, or some mechanical cause, must be 
looked for. 

(222) 



STOMATITIS AIMlTllosA. 



223 



Symptoms. — The usual symptoms of pain, byperaemia, and Bwelling 
are noted. The lining of the mouth is puffed and hyperaemic. The mucous 
membrane is covered with small, round prominences due to the swelling of 

the muciparous follicles. When the ducts of the latter become closed the 
glands dilate and there are produced cysts, the contents of which are clear. 
viscid mucus. We also find slight epithelial abrasions, sometimes leading 
to the production of a deeper process ; at all events important in that they 
mav become the seat of infection. The lymphatics are usually involved, 
and they serve as a guide to the intensity of the inflammation. Cases are 
on record where the temperature reached 104° F. in the rectum, but these 
are rarities. 

The prognosis is invariably good. Unless some chronic disease is the 
seat of this trouble there are rarely any disagreeable after-effects. 

Treatment. — The treatment consists in cleanliness. Eemove the cause 
if possible. Eemove mechanical irritants, such as diseased or sharp-pointed 
teeth. Boric acid. 1 per cent, solution, or sulphocarbolate of zinc or sulpho- 
carbolate of soda, 1 grain to the ounce, are valuable local astringents. At 
times nitrate of silver ("2 grains to the ounce) will act well when applied 
locally. Forchheimer recommends the application of silver nitrate when 
there is loss of epithelium. Cysts should be opened and their walls cau- 
terized when necessary. My best results are obtained by the use of argyrol, 
5 to 10 per cent, solution. 



Stomatitis Aphthosa. 

This condition is not follicular and has nothing to do with the mucip- 
arous follicles, as it is found in places where there are none. 

It consists in a hyperemia of the mucous membrane of the mouth 
associated with superficial ulcers. 

Causes. — There seems to be a decided reason for believing that this 
disease is of microbic origin. Aphthous ulcerations have been seen in 
children partaking of milk from cows that suffered with foot and mouth 
disea-e. Demme 1 reports a case of twins fed on goat's milk, the goat having 
foot and mouth disease. The milk was fed fresh and raw. One of the 
twins, the boy, had a severe aphthous condition of the entire mouth and 
throat, and died after seven days of illness. The other, a girl, was also 
sick with aphthous sore mouth, but recovered after five days' illnes-. 

Robinson 2 reports a severe epidemic of aphtha? acquired from foot 
and mouth disease in Devonshire. Two hundred and five persons were 
affected in one week. Two children died, the aphthous condition having 
extended to the respiratory tract. 



1 Vienna Medical Journal, vol. vi, 1883. 

2 London Practitioner for 1884. 



224 



DISEASES OF THE MOUTH. 



Boas, of Berlin, has also reported eases of foot and month disease and 
their results. Bohn states that the disease is most common between the 
tenth and thirteenth months of life. Therefore, teething has something to 
do with the eruption. Siegel studied an epidemic of foot and month dis- 
ease, resulting in aphthous stomatitis in children. An ovoid bacillus 0.5 /a 
long was found in all cases. We can assume that foot and month disease 
in cattle is the etiological factor of stomatitis aphthosa in the human being. 
Symptoms. — White or yellowish-white epithelial spots are seen singly 
or in groups, surrounded by an areola and developing anywhere in the 

mouth. In many cases 
they extend into the 
pharynx, and Forch- 
heimer believes into 
the larynx. This dis- 
ease is frequently as- 
sociated with acute 
gastric catarrh, consti- 
pation, and with gen- 
eral toxaemic condi- 
tions. The eruption 
may be preceded by 
pain in the throat, 
fever, enlargement of 
the lymphatics, and a 
general train of nerv- 
ous symptoms so com- 
mon in children. 

The diagnosis, 
therefore, will be diffi- 
cult until the erup- 
tion appears. The 
spots frequently are 
absorbed. Successive crops may come and go. 

Treatment. — The treatment consists in giving laxatives such as rhu- 
barb and magnesia, or inf. senna comp. The diet must be regulated. If 
the child has been given solids they should be excluded. The discontin- 
uance of milk is frequently beneficial. 

Locally, a weak solution of listerine as an antiseptic can be used. If 
the child is old enough it should rinse its mouth and gargle its throat with 
the same. Xitrate of silver, 10 grains to the ounce, or in some instances 
tincture of chloride of iron, has served me very well. The glycerite of car- 
bolic acid applied with absorbent cotton is frequently efficacious. 




Fig. 59a.— A Case of Sprue (Thrush) due to Faulty- 
Hygiene of the Mouth. Note Threads (Mycelium) and 
Small Oval Bodies (Spores). (After Jagic, Klinische Mi- 
kroskopie . ) 



STCtt I A TITI S M YCOSA. 



225 



Bednar's Apht n m. 

These arc seen on the soft palate. They may be mistaken for the 
ulcers produced by the breaking down of milia or retention cysts, or from 
that condition described by Epstein in which there are congenital defects 
in the mucous membrane filled up with epithelial detritus (Forchheimer). 
They are always the result of violence in cleaning the mouth. They are 
benign and get well without treatment. Frequently an improperly-shaped 
nipple will cause this condition by pressing on the palate. Changing the 
nipple will remove the cause. 

Dr. A. Jacobi, in the Archives of Pediatrics, says: — 
"Do not be so fearfully clean. Perhaps it is best to leave the infant's 
mouth alone with the exception of the first washing with sterilized water 
immediately after birth. Otherwise the mouth should be cleaned by the 
baby's feeding and by the practice I have recommended these dozen of years 
— viz. : to give a teaspoonful or two of water after every feeding. That will 
wash down all remnants of food that might get decomposed in the mouth. 
These 'aphthae' will get well when left alone; but as long as there is a 
sore surface there is a possibility of microbic invasion; for that reason 
alone they should be treated. Use a soft brush in the mouth every hour 
with a few drops of chlorate of potassium solution, one to thirty, or milder, 
but do not rub or be rough." 



Stomatitis Mycosa, or Parasitic Stomatitis. 

This disease is commonly known as thrush, sprue, soor, or muguet. 
It occurs in the mouth in the form of yellowish-white spots and is due to 
a microbe. A fungus was first discovered by Berg, of Stockholm, and called 
o'idium albicans by Eobbin. Forchheimer states that the fungus is found 
in two forms, the yeast form and the globulo-filimentous form (frequently 
called mycelium). "There is no ascospore, therefore. Eoux and Linoissier 
state that the fungus is not a saccharomyces. The chlamydospore has, 
however, not been satisfactorily worked out." 

Propagation goes on in three ways : by filaments produced from conidia, 
by isolated conidia, and by spores. 

Symptoms. — Local symptoms vary with the severity of this condition. 
At times no symptoms precede the appearance of these small spots. The 
spots are grayish-white or creamy in color. They may be elevated above 
the surface of the mucous membrane. They are not confined to the gums, 
but appear frequently on the lips, tonsils, pharynx, and cheeks. There is 
a fetid breath due to the inflamed gums. Children that are old enough to 
complain do not describe any subjective symptoms. The lymphatic glands 
are always enlarged and do not suppurate. When suppuration takes place 
it will follow after the disease in the mouth has disappeared. 



226 DISEASES OF THE MOUTH. 

Treatment. — Prophylactic treatment of the mouth, consisting in the 
nsnal hygienic measures, can prevent this condition. Aseptic details must 
be rigidly enforced in the nursing bottles and nipples when this disease is 
present. 

Treatment consists in the application of a 1 per cent, boric acid solu- 
tion as a mouth cleanser, followed by the local application of a 3 per cent, 
chlorate of potassium solution. Where a specific cause exists, such as 
carious teeth or dead bone, the same should be removed before attempting 
to cure this condition. 

Croupous Stomatitis, or Diphtheritic Stomatitis. 

This rare condition is occasionally met with in children. The prog- 
nosis and treatment should be considered just the same as though we were 
dealing with diphtheria in the throat. The following interesting case was 
sent to my clinic at the New York Post-Graduate Medical School in 
1894:— 

The child was seven months old, female, breast-fed, had always been in good 
health. No family history of tuberculosis, lues, rheumatism, or epilepsy. The child 
was vaccinated when about six months old, had had no previous illness excepting 
slight irritability about the time of the eruption of the first tooth. It has two 
teeth, incisors, lower jaw. General appearance not anaemic or rachitic, has well- 
nourished muscles and a fair amount of fat. Skin has a healthy appearance. Four 
other children in same family; three apparently healthy; the fourth is convalescing 
from an attack of "sore mouth." The infant has been gaining weight regularly since 
birth. It now weighs 15 pounds and 8 ounces. 

An examination of the infant showed: Two large patches — one on the tip of 
the tongue; the other on the soft palate — which were irregular in outline, yellowish- 
green in appearance. Temperature in the rectum I00y 5 ° F., at 11 a.m.; pulse, 142; 
respiration, 39. Cervical glands considerably enlarged on both sides. No history 
of existing infectious disease in the same locality. The diagnosis of stomatitis 
ulcerosa was made and a question mark ( ? ) entered after the same. Diphtheria 
was suspected. The mother was cautioned in regard to the other children, and the 
case carefully watched. I again saw the case two days later and found the child 
in a worse condition. The temperature in the rectum at 4 p.m. was 1021^° F. ; 
pulse, 160; small, feeble, but quite regular. The examination of the mouth showed 
an extension of the inflammatory condition of the patches, now involving the uvula 
and left tonsil. The pharynx showed an abnormal redness, but no membrane was 
visible. 

The mother's breast was painful on palpation. The glands were distended 
with milk, and the axillary glands enlarged and tender on palpation. The mother 
complained of aching in her limbs — a "tired feeling," as she called it — and had 
chills, alternating with fever. Her temperature was 99%° F. in the mouth. 
There were membranous patches around one of her nipples. This resembled a 
cracked nipple. While examining the infant's mouth I saw what appeared to be 
membrane. A similar condition was found around the nipple. I inoculated two 
agar-agar tubes and placed them in the thermostat. After thirty-six hours, small 
colonies of both streptococci and bacilli could be seen. On staining with Loeffler's 



STOMATITIS GANGREN< >SA. 



227 



alkaline methylene blue, showed distinct semblance to KJebs-Loeffler bacilli. A 
culture was made from the patch in the month, from the uvula, and also from the 
pharynx. The tube inoculated with the inula patch and the one from the tongue 
contained, in almost pure culture, the characteristic Klebs-Loeffler bacilli. The usual 
method of treatment and active stimulation was given. Concentrated liquid diet 
i rectal feeding i was given when the infant refused the breast An important 
question suggested itself: Shall we wean the infant? or. mother and infant having 
the same disease, could the infant be nursed on the healthy breast? It will be 
remembered that only one nipple was diseased. I resolved to give the infant the 
milk of the healthy breast and to guard against another sore nipple by nursing 
through a glass nipple shield. The milk in the diseased, or left, breast was drawn 
out with a breast-pump and thrown away. 

Three weeks after the apparent cure of the mother's breast and also after the 
last visible membrane from the infant's throat disappeared, the mother complained 
that she slept with one eye open. On examination. I found a distinct facial paralysis 
on the right side. The diagnosis was strengthened by the sequel in the case. To 
sum up: I believe the infant, while having diphtheria, infected its mother through 
the fissure of the breast during the act of nursing. Considering the physiology of 
nursing, we know the role played by the tongue, and. as the disease was first mani- 
fested thereon, it can be readily seen how this might have been inoculated from 
tongue to the breast through its cracked nipple. 

Syphilitic Stomatitis. 

Primary infection in syphilis is by no means rare. It usually occurs 
by transmission from a wet-nurse suffering with syphilis. 

A case of this kind was seen by me in an infant nine months old. This 
infant was accidentally infected by a woman who nursed it during the mother's 
illness. She had erosions ( cracked nipples ) and did not know that she suffered with 
syphilis. Her own child died of distinct syphilis, having had pemphigus and the 
general cachexia so common in luetic conditions. This case was given small doses 
of calomel, and given a bichloride bath (see chapter on •'"Syphilis" i and showed signs 
of improvement almost immediately. In the mouth of this child the ordinary mucous 
patches were found. 

Treatment is that of syphilis. (See chapter on "Syphilis.") 



Stomatitis (taxgrexosa (Noma: Caxceum Oris 1 ). 

This disease is frequently called noma, and sometimes cancrum oris. 
It i- characterized by a gangrenous destructive process located on the 
cheek. Although the left cheek is the favorite site of the disease, it can 
frequently be found on both cheeks. The writer has met with children 
suffering from this disease on the right cheek. Girls are more liable to 
noma than boys. It is usually secondary to some infectious disease, and 
has been known to follow typhoid fever, smallpox, scarlet fever, measles, 
pertussis, and allied infections disorder-. We must therefore assume 



1 Extracted from the American Journal of the Medical Sciences. April. 190: 



228 DISEASES OF THE MOUTH. 

that the infectious diseases are predisposing factor? in the development of 
this disease. 

Some authorities claim that noma frequently is a sequel to infectious 
diseases. 

The process usually commences on the gums or the inner portion of 
the cheek, and spreads very rapidly to the adjacent tissues. Thus it is 
that it will destroy the inner portion of the cheek and spread to the outside, 
causing similar destruction to the healthy tissues. From the nature of the 
method of spreading it appears to be of a specific nature. Whether or not 
a specific micro-organism causes this disease has not yet been definitely 
determined. We know, however, that it commences similarly to a diph- 
theritic process and spreads in the same manner. Weak children, as those 
above mentioned, that have passed through severe infections, are the ones 
usually attacked by this disease. 

Symptoms. — The cheek will appear swollen, hard, and cedematous to 
the touch, the oedema causing such swelling that frequently the eye of the 
affected side cannot be opened. There is a decided fetor to the breath, 
which is often the first symptom noticed. The disease spreads very rapidly 
from the gums to the cheek. Frequently the teeth will loosen and fall 
out. The latter is frequently caused by the previous administration of 
mercury. Thus it is that great care should be used in giving mercury to 
children. 

That it is not an inflammatory disease can be seen by the fact that 
the temperature is rarely or never above normal. The swelling can best 
be felt by opening the mouth and grasping the cheek between the thumb 
and forefinger. The skin over the induration is frequently mottled with 
purple spots resembling ecchymoses. The appetite is diminished, partly 
due to the fear of pain caused by chewing. 

Some authorities state that children so affected have diarrhoea. Foreh- 
heimer believes that haemorrhages rarely occur, owing to the blood-vessels 
being filled with thrombi. 

When this gangrenous mass discharges we will find a dirty, fetid 
saliva, with threads of broken-down tissue. The cervical glands in the 
immediate vicinity are always found enlarged. In severe cases it is not 
rare to have the parts ulcerate and even perforate the cheek after several 
days. Whan the disease extends inward, not only does periostitis occur, but 
necrosis of the jaw-bone has been noted. When the disease is as malignant 
as has just been described, then subnormal temperature, possibly delirium, 
may complicate the condition. The disease may extend to the lungs, caus- 
ing a gangrenous infiltration. When the gangrene affects the genitals in 
girls, then a serious prognosis must be given. 

Starr maintains that noma makes it? appearance uniformly at one 
point on the cheek, and is unilateral, which suggests a localized causative 



STOMATITIS GANGRENOSA. 229 

lesion. The most natural theory, that of embolism of a large arterial 
branch, due to weakness of the cardiac muscle or increased coagulability 
of the blood — effects of the primary disease — is untenable, because, with 
the given conditions, emboli ought, at least occasionally, to be found in 
other positions, which does not happen. It is necessary to look rather to 
the nerves — namely, the trifacial, the facial, or the vasomotors. That the 
gangrene is due to a lesion of one of these seems to be borne out by experi- 
ments. Thus Magendie found that division of the trifacial in dogs caused 
destruction of the corresponding eyeball, and half of the tongue became 
dry, brown, and fissured, the gums spongy and hemorrhagic, and the teeth 
loose. "In animals tenacious of life — the batrachians, for example — the 
soft portions of the face are cast off in shreds, just as in spontaneous gan- 
grene. After three or four weeks only one-half of the f ce remains." 

A variety of bacteria can be found at the seat of lesion, but their 
presence has no etiological significance. The body of a child dead from 
noma has a gangrenous odor and decomposes quickly; the skin is shriv- 
eled and the face and the feet are cedematous. The gangrenous parts are 
converted into a blackish-brown mass, and the maxillary bones are naked, 
brownish in color, and britt'e. The nerves, when examined microscopic- 
ally, are yellowish in color but unaltered in structure, and the blood-vessels 
are thickened and filled with thrombi. In the uninvolved parts of the 
cheek there is a dense exudation, while the palate, tongue, and tonsils are 
swollen and covered with black scales and crusts. The lungs are the seat 
of hsemorrhagic infarctions, lobular or metastatic lobar pneumonia, and 
sometimes gangrene. The intestines are catarrhal. Evidences of the pri- 
mary disease may also be present ; for example, the lesions of typhoid fever 
or dysentery. 

The following case will illustrate the condition described :— 

Elsie G., aged 7 years, was seen by nie in January, 1900. The child had com- 
plained of severe headache for three or four days, and was very feverish. Her 
mother became alarmed because of persistent vomiting. She stated that the child 
vomited at least six times in twenty-four hours. She complained of feeling fatigued 
and had pains in her arms and legs. 

Small doses of quinine were given the child, but did not seem to relieve the 
present condition. 

The child was nursed for ten months, and was a strong baby up to this time; 
dentition commenced at the seventh month; the child's muscles and bones were 
well developed; there were no evidences of rickets; the first two years were passed 
without any sickness except an occasional attack of constipation. The child walked 
at the end of the first year and commenced talking at its fouiteenth month. Twenty 
teeth — "milk teeth" — appeared at the end of two years. The child had measles in its 
third year, which left a bronchitis; the mother states that this same cough recurs 
every winter. The child has had whooping-cough, lasting four months, which was 
bo violent that it had epistaxis almost every day for one month. This whooping- 
cough was so severe that, in addition to the nose-bleed, the child vomited almost 



230 



DISEASES OF THE MOUTH. 



continuously. From loss of sleep, in addition to the above-named symptoms, the 
child commenced to emaciate. This was at the end of her fifth year. 

She lost twelve pounds in two months, and the mother states that since that 
time she has been very puny and delicate. There is also a hernia directly traceable 
to the violent paroxysms of cough. 

The mother suspected the child was suffering from malaria, or possibly an 
attack of grip. When the child was undressed an eruption was found all over the 
body, which was that of typical scarlet fever. The throat was filled with evidences 
of pseudo-membranous patches which were distinctly scarlatinal in character. The 
temperature was 103.4° F., taken in the rectum; pulse, 128: respiration 22. The 




Fig. 60. — Case of Stomatitis Gangrenosa (Noma) Following Scarlet 
Fever. The picture shows the unilateral gangrenous condition involving 
the right cheek and the lips. Case recovered. Clinical history given in 
the text. (Original.) 



child was put to bed and an expectant plan of treatment ordered, in addition to a very 
light liquid diet consisting of soup, milk, buttermilk, broth. Nothing else was 
allowed; no solids were given. For the thirst I ordered orange juice and apple 
sauce. Small doses (wine-glasses) of citrate of magnesia were given for their laxa- 
tive and diuretic effects. 

Desquamation followed in the second week in the usual manner. The urine 
showed traces of albumin in the second week, which increased until that time — 6 
per mille, according to Eschbach's albuminometer — hyaline and epithelial casts were 
found in great numbers. There were also large quantities of blood-corpuscles visible 
under the microscope. The urine was quite red from the blood that it contained. 
At the end of the third week there was quite an anuria. This latter condition was 
relieved by the application of several dry-cups over the region of the kidneys. Five 
to 10 grains of diuretin internally were ordered every four hours. Citrate of 



EPITHELIAL DESQUAMATION OF THE TONGUE. 231 

potash was given, 5-grain doses combined with large quantities of Apollinaris and 
lithia water. After three weeks of patient treatment the child recovered. 

The heart sounds were not only very feeble, but thready, and a loud, blowing, 
hsemic murmur, which was attributed to the anaemic condition, was audible. Iron 
was given in the form of the syrup of iodide of iron; hypophosphites were also 
administered as restoratives. Convalescence lasted in all until April, a period of 
almost three months from the time of the child's first illness. About this time she 
complained of pain in the gums and on the cheek while chewing. Later, the foul 
breath attracted attention. At first this condition was attributed to the teeth, 
but a dentist who saw the child found the teeth and gums healthy. The ulceration, 
which had now become quite marked, from the size of a silver dollar, spread with 
remarkable rapidity. Its color was that of a dirty, blackish-gray, and had purpuric 
spots scattered around the edges of this ulceration, resembling subcutaneous haemor- 
rhages. On examining it considerable fluid, which was very foul smelling, exuded 
on pressure. Antiseptic lotion, consisting of 50 per cent, peroxide of hydrogen 
diluted with water, was ordered as a mouth wash. The child was told to rinse the 
mouth every half-hour, especially after eating. The gangrene extended to the out- 
side of the cheek, involving, as can be seen by the illustration, almost the whole 
cheek. The picture was taken after the child had had its mouth and its cheek thor- 
oughly cauterized by using the Paquelin cautery. Ichthyol was applied in the fol- 
lowing manner: — 

I£ Ichthyol one part and lanolin ten parts. 

M. Ft. ungt. Sig. : Apply over the whole of the gangrenous surface by 
rubbing the parts thoroughly, the same to be repeated at least three or four times 
a day. 

The ichthyol seemed to serve remarkably well in this case. The same was 
continued for about three weeks, when the child was discharged as cured. 

Epithelial Desquamation (Geographical Tongue). 

A very common condition consists of epithelial desquamation of the 
tongue, giving rise to irregular, round or crescent-shaped patches. The 
borders of these patches are surrounded by a thickish, grayish margin. The 
center has a glazed appearance. From the irregular outline resembling a 
map the name of geographical tongue originates. 

There are usually two or more of these red patches seen at one time. 
They last weeks and months. I have met these cases among the poorest 
hygienic surroundings and have seen the same condition among the wealthy. 
Malnutrition seems to be associated in all my cases. I have frequently seen 
cases of this kind among the children suffering with diphtheria at the 
Willard Parker Hospital, especially during convalescence. The following 
case illustrates this condition: — 

Minnie H. Fourteen months old. Has been in delicate health since birth. 
Although breast-fed. has always been constipated and suffered with gastritis, and 
vomiting occasionally. 

She is very anaemic. Can neither stand, walk, nor talk. Dentition has been 
delayed; there is no sign of teeth. The tongue shows four large irregular shaped 



232 DISEASES OF THE MOUTH. 

patches and two smaller ones in the center. They appear as though a coated 
tongue had irregular patches of red, and sinning flesh interspersed. Diagnosis, rickets 
and geographical tongue* 

Treatment. — Increase the proteids and fats to stimnlate nutrition. 
Cleanse the tongue with boric or tannic acid solution. Most authors advise 
no treatment. 

Congenital Hypertrophy of the Tongue. 

A thickened swollen tongue is always seen in sporadic cretinism. (See 
chapter on "Cretinism.") The specific thyroid treatment will usually 
modify this enlargement. When diseased lymphatics exist we may have 
a lymphangioma. Such conditions are rare, and if present require surgical 
treatment 

Bifid Tongue. 

Brothers reported a case of this kind to the New York Pathological 
Society. The child was one month old, had a cleft tongue and a fissure of 
the soft palate. 

Bifid Uvula. 

This condition is occasionally seen. I have seen bifid uvula several 
times without cleft palate. Some authors report the co-existence of bifid 
uvula with cleft palate. It requires no treatment. 

Glossitis. 

An inflammation of the tongue is very rare in children. Some authors 
state that it is due to traumatism, such as biting the tongue in an epileptic 
fit, or a ragged sharp tooth may infect the tongue and cause inflammation. 
Any irritation, such as caustic acids or alkalies, may cause inflammation. 

The following case occurred in my private practice: — 

A child 1 year old was bottle-fed, and suffered with severe constipation. He 
was backward in development, had no teeth, could neither walk nor talk. Several 
adults in the family had influenza and the child was exposed and infected. The 
fever reached 104° F. There was anorexia, cough, and running of the nose. The 
tongue was thickened and inflanied and protruded from the mouth. He refused to 
take any food and seemed relieved when a piece of ice was placed on the tongue. Ice 
cream was ordered to nourish and cool at the same time. Rectal suppositories con- 
taining aconite, 1 minim, and sodium salicylate, 3 grains, were ordered every two 
hours. Under this treatment, aided by ice applied on the tongue and an ice collar 
on the neck, the swelling of the tongue disappeared in about four days. 

Eanula. 

A swelling in the floor of the mouth, located on either side of the 
frasnum, is frequently met with in children. It is a cyst varying in size, 



PLATE VII 




Geographical Tongue, or Epithelial Desquamation. 
(Original.) 



ALVEOLAE ABSCESS. 233 

and is due to an occlusion of (he duct leading into the mouth from the 
sublingual gland. 

Character. — It may he simple or multilobular. It may he of such pro- 
portions as to interfere with proper nutrition. 

Symptoms. — The symptoms are those of a mechanical obstruction of 
a non-inflammatory character. It is painless, soft, fluctuating, and con- 
tains mucus. The color of the growth is the same as that of the adjacent 
parts. 

Treatment. — An incision should be made to evacuate the contents of 
the sac. The interior of the sac should be cauterized with iodine or nitrate 
of silver. In some instances the Paquelin cautery may be required. 

Alveolar Abscess. 

AVhen there is defective hygiene in the mouth and the teeth are not 
properly cleaned, caries of the teeth results. The carious condition fre- 
quently sets up an inflammation, and pyogenic bacteria gaining entrance 
cause abscess formation at the root of the tooth. 

Symptoms. — The symptoms are pain, swelling, fever, interference with 
feeding, foul breath, and general constitutional disturbances. The diag- 
nosis can be made by the presence of fluctuation in the mouth, by the 
swollen face, mouth, and jaw. 

Treatment. — Locally, warm (dry) chamomile bag or warm (moist) 
flaxseed poultices will have a soothing effect, used externally over the swell- 
ing. Rinsing the mouth w T ith warm chamomile tea to which a few drops 
of listerine have been- added is grateful. Painting the gums with equal parts 
of tincture of iodine and tincture of opium every hour will relieve pain. 
If fluctuation is detected an incision should be made into the gums on the 
inner surface, and the pus evacuated. If this condition is neglected the 
periosteum of the jaw may be involved and the pus will burrow and evacuate 
itself spontaneously, leaving a disagreeable fistula. Cases have been reported 
where neglect of this condition has resulted in necrosis of the jaw. 

Angina Ludovici. 

Angina Ludovici is an inflammation of the cellular tissue of the floor 
of the mouth and neck. It is probably a form of actinomycosis. The 
swelling is most marked below the jaw of one side. The symptoms are 
very intense and both local and general. There are general septic symptoms 
from the outset. With the swelling there are oedema and board-like indura- 
tion. I'edness and the rapid formation of an abscess occur rarelv. The 
throat is not affected. Death takes place from reflex suffocation or in 
coma. 



CHAPTER II. 
DISEASES OF THE (ESOPHAGUS. 

Acute Oesophagitis. 

An inflammation may extend from the pharynx into the oesophagus. 
When such conditions arise the symptoms of pain on swallowing are asso- 
ciated with fever. The treatment consists in giving bland food, milk, 
.seltzer, and alkaline waters or water containing bicarbonate of soda. 

Croupous or Diphtheritic Oesophagitis. 

Diphtheria can invade the oesophagus as well as it can spread to the 
larynx. Some authors describe croupous inflammatory patches in the 
oesophagus. I have seen diphtheria of the oesophagus and also a diph- 
theritic patch post-mortem in the stomach of this same case. Such a con- 
dition is invariably serious and recovery is rare. The treatment of diph- 
theria affecting the oesophagus is the same as that described in the chapter 
on "Diphtheria." When dysphagia occurs and there is an interference with 
deglutition, rectal feeding may be demanded to save life. 

If severe pain exists give morphine or codeine in suitable doses. Nau- 
sea and vomiting can best be controlled by giving large doses of chloral. If 
an oesophageal stricture remains then surgical treatment will be required, 
for which the reader is referred to modern text-books on surgery. 

Eetro-cesophageal Abscess. 

This condition may follow measles, scarlet fever, or diphtheria ; in fact, 
it may be associated with any infectious disease. As a rule, this disease con- 
sists of a breaking down of the lymph glands ending in suppuration. In 
a case seen by me the streptococcus was found. This condition is also 
frequently associated with tubercular conditions. The following case will 
illustrate the type most frequently met with: — 

I was called in consultation with Dr. S. Brothers to see a child 3 years old 
with the following history: — 

There was fever, an irritant cough, stertorous breathing, and evidence of 
obstruction pointing to the larynx. The neck was swollen and the glands enlarged. 
The temperature was 102° F. ; pulse, 130; respiration, 36. At first the case resem- 
bled one of laryngeal stenosis as is usually found in diphtheria. The dyspnoea was 
so marked that intubation was suggested. The symptoms of dyspnoea continued, 
and an incision was made into the posterior pharyngeal wall. The abscess cavity 
extended into the oesophagus. Caries of the dorsal vertebrae was associated with 
this condition. The child died from inanition. The tubercular process was evidently 
(234) 



• 



FOREIGN BODIES IN THE (ESOPHAGUS. 235 

responsible for the abscess, which consisted of pus and large curded masses. The 
diagnosis was made after a careful study of the case. It is not an easy matter to 
diagnose this condition, as it is absolutely impossible, in some cases, to reach the 
abscess cavity by a digital examination of the pharynx. 

In the case above reported the dyspnoea was very alarming. The litera- 
ture records cases of spontaneous evacuation of the abscess into the oesoph- 
agus resulting in recovery, but usually these eases end fatally. The treat- 
ment is surgical, and tuberculosis, if present, requires the usual form of 
treatment. (See chapter on ''Tubereulosis.*') 



Foreign Bodies ix the (Esophagus. 

I have frequently been consulted regarding the removal of buttons, 
coins, etc., which were swallowed. The habit of children to put everything 
into the mouth should be remembered when buvincr tovs. 






Fig. 61. — Hinged Bucket. 

The best method of extracting foreign hodies in the oesophagus is by 
means of the hinged bucket ; also known as the "coin catcher/* 



J 



CHAPTER III. 
DISEASES OF THE STOMACH. 

The Infantile Stomach. 

The infantile stomach is vertical and cylindrical and the fundus but 
little developed. Thus, whenever there is a tendency to vomit, the anti- 
peristaltic motions do not press against the fundus, but directly upward. 
There is, therefore, rather an overflow than a vomiting of the gastric con- 
tents; this takes place so easily that the babies are not disturbed by it. 1 

Anatomy. — The muscular development is weakest at the fundus. Ac- 
cording to Fleischmann, the oblique and the longitudinal fibers described 
by Henle, which have their origin at the pyloric opening, "do not exist in 
the infant." The investigations of Leo and von Puteren show that, in spite 
of this lack of muscular development, the stomach of a nursing infant is 
emptied in one and a half or two hours. With food that is more difficult 
to digest, the gastric contents are propelled more slowly. 

The Mucous Membrane of the Stomach. — The mucous glands are far 
more numerous on the pars pylorica than in adults, whereas they are far 
fewer in number at the cardia. 

The mucous membrane of the infant secretes gastric juice which, in 
general, is similar in properties to that of the adults. The amount of secre- 
tion in the infant is far less than in the adult, while its chemical constitu- 
tion is the same, namely: pepsin, lab-ferment, and acids. The exact pro- 
portion of the ferment and pepsin has not yet been studied sufficiently to 
admit of any positive deductions being made. 

Physiology. — It is very important to know that the mucous membrane 
of the mouth is practically dry at birth; the secretion of saliva is very 
small, and, according to Korowin and Zweifel, increases toward the end of 
the second month. 

The fermentative (sugar-forming) property of saliva, which is trifling 
at the commencement, increases with the quantity of the saliva secreted. 
This is essentially true of other secretions; thus, the pancreatic juice does 
not have the same emulsifying properties in the infant as in adults. 

The nursing or sucking center is located, according to experiments 
made on animals by Basch, in the medulla oblongata on the inner side of 
the corpus restiforme. 

The sucking act is reflex ; according to Auerbach, the muscles of the 
tongue participate most actively. 



Jacobi, "Therapeutics of Infancy and Childhood," page 25. 
(236) 



IYSIOLi ".\ OF THE STOMACH. 



Acids in the Infant's Stomach. — The gastric contents in a nursling 
contain two acids: il) Irydrochloric acid; c2) lactic acid. The relative 
acidity is smaller than in adults, the highest point being reached one and 
a half hours after nursing. According to von Puteren. the acidity is two 
and one-half to three times as small as in the stomach of adults. Accord- 
ing to Leo, the acidity of the gastric juice of nurslings iy 2 hours after 
drinking is only 0.13 per cent., whereas, in the adult, after the same time, 
the acidity is from 1.5 to 3.2 per cent. According to Wohlmanu, free HC1 
can be found in healthy nurslings from l 1 ^ to 2 hours after taking food. 
The percentage of free HC1 ranges from 0.83 to l.S per cent. 

Lactic Acid. — The quantity of lactic acid is. according to Heubner. 
between 0.1 and "A per cent. 

Pepsin and Hydrochloric Acid. — There are two chief functions of the 
pepsin and hydrochloric acid which are the same in both infant and adult : 
First, the power of killing bacteria : a real bactericidal power. Second, as 
a solvent for albumin. Thus, it is apparent that pathogenic micro-organ- 
isms that might have entered the stomach can be destroyed, although we 
know the small quantity of acid is hardly able to cope with large quantities 
of food contaminated with bacteria. 

Unorganized Ferments. — The unorganized ferments seem to be nitrog- 
enous bodies; their exact composition is unknown, and it is doubtful if 
they have ever been obtained perfectly pure (Landois and Stirling). 

Action of the Saliva on Various Bacteria. — Triolo describes a series 
of interesting experiments with saliva. He first irrigated the mouth with 
bichloride or permanganate of potash solution, followed this by irrigation 
with sterilized water until the disinfecting substances were removed, and 
then inoculated the surface of various culture-media with the sputum. His 
results proved that Baliva possesses a distinct bactericidal property, for 
cultures of five-day-old bacteria were destroyed, as well as fresh bacteria 
eighteen hours old. 

This property, however, was lost when saliva was filtered. The saliva 
of the parotid and submaxillary glands, taken singly, were equally effica- 
cious as their combined secretion. He believes that the greatest bactericidal 
action is due to the secretion of the mucous glands in the mouth. 

The Influence of Gastric Juice on Pathogenic Germs. — Gastric juice is, 
according to the experiments of Drs. Kurlow and Wagner, an exceedingly 
strong germicidal agent, and when living bacilli get into the intestinal 
canal it is due to various conditions entirelv independent of the gastric- 
juice. When the latter is normal and in full activity, only the most prolific 
microbe? — such as tubercle bacilli, the bacilli of anthrax, and perhaps the 
staphylococci — escape its destructive action : ?11 others are destroyed in less 
than half an hour. Similar influences exist in the intestines, as proved by 
inoculation with the cholera bacilli. 



238 



DISEASES OF THE STOMACH. 



Table No. 53. — Showing the Unorganized Ferments Present in the Body 
and Their Actions. 



Fluid or Tissues. 



Ferment. 



Actions. 



Gastric juice 



Pancreatic juice 



Intestinal juice 



Blood . . , 
Chyle . , 
Liver (?) . . 
Milk . 
Most tissues 



Muscle 
Urine 



Blood 



Ptyalin 

1. Pepsin 

2. Milk-curdling 

3. Lactic-acid ferment. 

4. Fat splitting 

1. Diastasic, or amylopsin 

2. Trypsin 

3. Emulsive (?) 

4. Fat-splitting or steapsin 

5. Milk-curdling. . . . 

1. Diastasic 

2. Proteolytic 

3. Invertin 

4. Milk-curdling .... 



Diastasic ferments 



Pepsin and other ferments 



Converts starch chiefly into mal- 
tose. 



Converts proteids into peptones in 
an acid medium, certain by- 
products being formed. 

Curdles casein of milk. 

Splits up milk sugar into lactic 
acid. 

Splits up fats into glycerine and 
fatty acids. 



Converts starch chiefly into mal- 
tose. 

Changes proteid into peptones in 
an alkaline medium, certain 
by-products being formed. 

Emulsifies fat. 

Splits fat into glycerine and fatty 
acids. 

Curdles casein of milk. 



Does not form maltose, but mal- 
tose is changed into glucose. 

Fibrin into peptone (?). 

Changes cane-sugar into grape- 
sugar. 

In small intestine (?). 



Fibriu-forming ferment 



Judging from the results of experiments made by Zagari^ Straus, and 
Wurtz, who exposed various pathogenic organisms, among others that of 
tuberculosis, to the action of gastric juice, we must come to the conclusion 
that, so long as the gastric juice retains a sufficient degree of acidity, tuber- 
culosis of the alimentary canal will be unlikely to occur. 

Albumin and the Gastric Juice. — Another property of gastric juice in 
infants is the transformation of albumin in the following manner: (1) 



- L\< II CAPACITY. 

albino then peptone, (3) and lastly syutonin. It is thus appar- 

ent that, although the infantile stomach plays a subordinate role as a nour- 
ishing organ, it cannot be denied that fluid substances — like water, a solu- 
tion of salt, aud solution of sugar — are absorbed, and in a less degree albu- 
min also. The relative size and capacity of the stomach prevent the func- 
tion from being as thoroughly developed as in the adult. 

- iach Capacity. 

- birth the infant's stomach has a capacity of from 9 to 11 drachms, 
or 35 to 43 cubic centimeters. At the end of one month it is about 2 ounces, 
or 60 cubic centimeters. 

Ax the end of three months the gastric capacity is about four times 
the amount at birth. The very rapid increase from birth to this time soon 

-. and the stomach capacity grows in size, but at a much slower rate 
of development (Baginsky). 

The series of experiments at the Children's Hospital of St. Petersburg, 
made by Ssnitkin. showed that the weight, and not the age, determined the 
capacity of the stomach, and shonld be used as a guide for the quantity of 
infant-food required. 

If the normal (initial) weight of an infant is 3000 to 4000 grams, or 
about 6.6 to 8.8 pounds, then */ im part, plus the daily increase in weight 
added, which normally amounts to from 2 / 3 to 1 ounce, would give the 
amount of food required. 

Biedert also regards the body weight as an important factor in deter- 
mining the amount of milk to be given. Baginsky argues that, while this 
rule will hold good for a great many infants, he must insist upon relying 
upon the scales to show just how much nutriment has been digested, and 
thus a regular system of weighing, plus the inspection of the stools, will 
aid in establishing the quantity of food necessary. "There is no unanimity 
among experienced clinical observers upon the subject of infant-feeding." 
The majority of clinicians the world over order cows' milk in varying 
dilutions. Some use the cereals; — like wheat, barley, rice, and farina — to 
dilute and subdivide the curd. Other clinical observers — Budin and Tariot, 
French observers — advise giving infants, at birth, whole mitk; that is. pure, 
undiluted cows' mill: 

The following illustrations will serve to show the difference in the 
capacity of infants' stomachs at various ages, taken by the author at the 
morgue of BeUevue Hospital. 




Fig. 62.— Infant's Stomach, Actual Size. From a Case of Malnutrition. Capacity, 
About 2 Ounces. When Stomach was Filled it Held 4 Ounces Easily. Author's Col- 
lection.) 




Fig. 63.— Infant's Stomach. Actual Size. Died Suddenly from Convulsions. Age 
Seven Months. Cause of Death, Eclampsia. Capacity when Filled with Water, 8% 
Ounces. (Drawn from Specimen in Author's Collection ) 



(240) 




Fig. 64. — Infant's Stomach. Capacity, 10 Ounces. Age of Child, Eleven 
Months. Cause of Deaih, Enteritis. (Drawn from Specimen in Author's Col- 
lection.) 




Fig. 6n.— Capacity of Measurement, 14 Ounces. Diseased Condition. Normal Capacity. 
Holding About 2 Ounces, or 50 Cubic Centimeters. (Author's Collection.) 

16 



(241) 



242 DISEASES OF THE STOMACH. 

Si xificaxce of Vomthng. 

Vomiting is a reflex act. It can be produced directly by irritating 
the stomach, as. for example, when mustard is swallowed. It can also be 
produced by a great many vegetable products, as. for example, by ipecac 
root. Mineral poisons, such as sulphate of zinc or turpeth mineral, or sul- 
phate of copper, will produce violent emesis. Bacterial fermentation from 
stagnant food can also produce vomiting. These causes are therefore direct 
in their action and produce immediate results. It is a great mistake to 
look upon the stomach or the stomach contents as the etiological factor in 
vomiting, and as the only organ capable of producing emesis. 

The toxins in the blood of many acute infectious diseases produce vom- 
iting. One of the earliest symptoms of scarlet fever is vomiting. Several 
days before the eruption of scarlet fever appears, vomiting of a most violent 
nature generally occurs. This is no doubt due to toxaemia. 

An irritation of the vagus or the pneumo-gastric nerves can result in 
vomiting. Any irritation brought about through the central nervoi;- - - 
tern will cause vomiting : thus it is that shock, fright, or disturbance of 
metabolism may produce vomiting of a most serious nature. 

Giddiness, caused by swinging or a rolling motion, as on a ship, may 
produce cerebral hyperemia, ending in vomiting. When a child falls on 
the back of its head and produces concussion of the brain, we have con- 
tinued vomiting as a first symptom. When vomiting persists in spite of 
gastric treatment, meningeal disease should be suspected. In meningitis, 
especially in hydrocephalus, vomiting is a frequent symptom. The writer 
- not presume that any physician will diagnose brain fever, scarlet fever, 
or gastric fever by the single symptom of vomiting. 

On the other hand, it is well to know that vomiting, with a suspicious 
rash and a sore throat, will strengthen the suspicion of an existing scarlet 
fever. A rule followed by the writer is to lay considerable stress on vom- 
iting. It means nothing if we are dealing with a spoiled stomach following 
a large dish of plum pudding. But woe to the physician who gives a good 
prognosis where vomiting is an early manifestation of intracranial disease 
that ends fatally. 

Acute Gastric Catarrh (Dyspepsia — Gastriti- 

One of the most frequent diseases met with in infants or young chil- 
dren is dyspepsia. This is due to improper feeding of both quality and 
quantitv of the food. Xursing children are very often seen suffering with 
this disease, especially among the tenement population. 

That the immediate surrounding s 3 so-called )i hygiene, have some 
1 tearing on the development of this disease is certain. Children reared in 
insanitary apartments cannot digest breast-milk as well as children living 



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ACUTE GASTRIC CATARRH. 243 

in largo, airy rooms, with good hygienic surroundings; thus it is wise to 
study the origin of this disease before commencing any specific treatment. 

The largest number of cases arc seen with bottle-fed babies. 3 1 is here 
that the physician will be called upon to exercise the greatest amount of 
judgment. Errors in feeding, particularly over-feeding, and giving the 
infant the bottle whenever it cries, must be looked upon as a means of 
aggravating and exciting gastritis, if not being the real cause of the 
dyspepsia. 

Pathology. — The mucous membrane of the stomach is always swollen 
and thickened. Occasionally erosions and haemorrhages are found. The 
tissue beneath the mucous membrane, the submucosa, will be found oedema- 
tous. The interstitial tissue is infiltrated with leucocytes, and the differentia- 
tion between the parietal and principal cells cannot be clearly outlined. 
All the cells appear cloudy and granular and partially separated from the 
membrana propria of the gland. There is an abundance of the mucous 
cells in the pyloric region, and this increase extends deeply into the ducts 
of the glands. 

When gastritis is met with in older children the origin of the trouble 
can easily be traced. Over-eating, especially cakes and pies and puddings; 
too rapid chewing and swallowing of unmasticated pieces will aggravate an 
attack of this kind. 

Gastritis is seen more often in older children who are permitted to 
drink wine or beer at the table with their parents. It is quite common to 
have, especially among the working classes, distinct evidences of alcoholic 
gastritis. Children are permitted to take a drop of whisky or wine or beer, 
as their parents say, "to strengthen them." 

In a large dispensary service with which the writer has been associated 
for the past fifteen years, among a large foreign and native-born element, 
it was found by careful questioning that more than 50 per cent, of the 
children brought to this service w T ere permitted to use stimulants. 

Tmvholesome feeding, candies, and ice creams have frequently caused 
acute gastritis in many children. 

Symptoms. — A young infant will suddenly refuse to take its bottle and 
will appear very peevish and thirsty, flex its legs on its abdomen, will seem 
dissatisfied, and refuse to play. Vomiting is a frequent symptom. The 
infant will cry and put its fingers in its mouth. The temperature on the 
first day ranges between 102° and 103° F., though it may reach as high as 
K)5° F. in the rectum. The pulse ranges between 140 and 160. The res- 
piration is sometimes accelerated. The tongue is usually coated with a 
white or a grayish-white fur, and there is a foetid odor to the breath. Diar- 
rhoea may be present, although constipation is more frequently met with. 

When children are extremely anaemic, or if from previous malnutrition 
they are rachitic, the disease will commence with convulsions. Convulsions 



244 DISEASES OF THE STOMACH. 

must not be looked upon as very serious unless they recur several times 
during the first day of the attack. 

A diagnosis of meningitis will frequently be made in the commence- 
ment of an acute catarrhal gastritis, unless \re study the pulse-rate. In 
meningitis the pulse-rate is usually slow; in gastritis it is greatly accelerated. 
Pressure on the epigastrium will show marked tenderness. The stomach 
is usually distended and tympanitic on percussion. 

If a child is old enough to complain, there are usually subjective symp- 
toms such as headache, frontal in character, and pains in the arms and 
legs will be described. Jaundice will usually be found in older children in 
the course of the disease, and denotes an extension of the catarrhal inflam- 
mation from the stomach into the duodenum ; thus gastro-duodenitis may 
be diagnosed when jaundice is established. 

Prognosis and Course. — The prognosis of an acute catarrhal gastritis 
depends on the time of the year and the condition of the child at the time 
of the attack. If a bottle-fed infant is attacked with gastritis in midsum- 
mer, and it cannot be removed from the sultry city, then the prognosis is 
grave. If. however, breast-milk can be given judiciously and the feeding- 
interval conform with the requirements of the weak digestive apparatus. 
then we may reasonably hoj:>e for a favorable termination. If complications 
occur, chief among which may be typhoid fever, or an extension of the 
disease from the stomach into the bowel, then the outlook will not be good, 
unless we can remove the patient to the mountains or seashore. 

Xephritis frequently complicates gastritis, and when such complica- 
tions exist the prognosis is bad. Infectious diseases complicating gastritis 
will render the prognosis unfavorable. 

The important point to note is. how much food is being assimilated. 
If the infant digests a proper quantity of food the prognosis is good; if, 
however, vomiting continues and we cannot feed the child per mouth or 
per rectum, then the prognosis is very grave. We must aim to prevent 
starvation if the child's life is to be saved. 

Treatment. — The first thing to do is to cleanse the stomach. This can 
be accomplished by giving a dose of castor-oil, syrup of rhubarb, or calomel. 
If the child is old enough some citrate of magnesia in wineglassful doses, 
repeated every two or three hours, will correct fermentation. When rapid 
cleansing of the stomach is demanded, owing to toxic symptoms from 
ptomaine poisoning or from other poisons, an emetic should be given. A 
dose of 1 grain of sulphate of copper in a teaspoonful of water, repeated 
every half-hour until vomiting is produced, will materially ail in cleansing 
the stomach. Syrup of ipecac, in teaspoonful doses, may also be given in 
some instances, although the writer does not advocate the use of syrups in 
acute fermentative diseases of the stomach or bowels. In other cases wash- 
ing the stomach with a soft catheter, as mentioned in the treatment 



A.CUTE GASTRIC CATARRH. 245 

of summer complaint, will prove very valuable. Several pints of table salt 
solution or of normal salt solution' can be used to thoroughly cleanse the 
stomach until the water is syphoned oil' quite clear. In washing the stomach 
with the aid of a soft-rubber catheter there is usually quite some irritation 
produced in the pharynx and (esophagus, and thus vomiting will usually 
aid in the lavage in clearing the stomach of its contents. When such treat- 
ment has been instituted it is advisable to allow the stomach to rest at least 
six or seven hours, and meanwhile give sterile water — "ordinary boiled 
water" — ad libitum. 

When the bowels have been properly cleansed and the stomach lias 
been washed by lavage, or treated with one of the above-mentioned laxa- 
tives, then the after-treatment will consist in preventing further fermen- 
tation, and also in toning up the patient's condition. 

Medicinal Treatment. — Experiments have shown that when the gastric 
contents have been syphoned off or examined immediately after an emetic 
has been given, in an acute gastritis, there is a deficiency of hydro- 
chloric acid. This is an indication then as to what is required. 

Diluted hydrochloric acid given in doses of from 2 to 5 drops has 
served the writer very well when given every three or four hours. 

R Acid hydrochloric dilut 1 drachm 

Essence pepsin (Fairchild) 2 ounces 

M. D. S. Teaspoonful repeated every two or three hours. 

Beta-naphthol bismuth in doses of 1 to 5 grains, every two hours, has 
served me very well. Calcined magnesia 2 is also very valuable. The fol- 
lowing prescription has been used with very good results in dyspeptic con- 
ditions attended with constipation : — 

1$, Magnesia usta 1 drachm 

Pulv. rhei 1 drachm 

Saccharine 2 grains 

M. and divide into 12 powders. One powder to be given in a teaspoonful of 
sterile water every two or three hours. 

Powdered charcoal added to the above prescription in doses of 1 grain 
three times a day is frequently useful. Salol in doses of 1 grain every two 
or three hours, and resorcin in doses of r / 10 grain or *4 grain, for a child 
1 year old, repeated three times a day, will do good in some instances. 

A very good liquid preparation sold in drug stores is milk of magnesia 
(Phillip's). It is an excellent antacid and corrective when flatulence 
exists. 



1 Formula? for saline solutions will be found in the chapter on "Scarlet Fever.'' 

2 Magnesia in powdered form I frequently use is known as Husband's Magnesia 
in drug stores. 



246 DISEASES OF THE STOMACH. 

When severe thirst exists boiled water may be given. This water may 
be acidulated with a few drops of diluted phosphoric acid, and will be 
found not only very grateful and cooling, but very serviceable if the child 
has a tendency to diarrhoea in midsummer. 

Dietetic Treatment. — The most important point to remember is the 
feeding. If we are dealing with the nursling, then breast-milk should be 
withheld for about one-half day. TVhen the breast is given again, the infant 
should not be permitted to nurse more than two or three minute-, 
immediately after taking the breast the infant should receive 3 or -I ounces 
- eetened rice water. In this manner we will give the infant diluted 
milk. This breast and rice-water feeding should be repeated in four hours, 
no sooner, no matter what the age of the infant. 

TVhat might appear very radical is simply advised, to prevent the stom- 
ach from j^erforming its usual amount of work until the gastric function 
is reestablished. If. however, the child's appetite warrants it, then one or 
two days should elapse before giving it its former regular quantity of nurs- 
ing. The guide to the return of the normal quantity of nursing will be the 
disappearance of the fever and of the accelerated pulse-rate. The child*? 
craving for the breast can be noted chiefly by constant crying when the 
breast is removed, and the ravenous manner in which it nurses. 

In bottle-fed babies it is advisable to give the child one-half of t - 
former quantity of milk or cream which it received at the time of its illness, 
and if it is found that the sugar contained in the food aggravate- this v- 
dition. a small quantity of saccharine may be used to sweeten the milk, and 
the sugar discontinued. Some children show distinct fermentative changes 
after the use of too much sugar. In such cases the use of saccharine or one- 
half teaspoonful of glycerine to each bottle of milk is sometimes beneficial 
as a temporary substitute. 

Glycerine is absolutely harmless and may be given for months with 
impunity. My rule is to insist on the use of sugar if at all possible. Lime 
water in doses of a teaspoonful or a tablespoonful may be added to the 
milk. Five grains of bicarbonate of soda may be added to the mil: r 
given before each feeding. If vomiting follows the milk-feeding, whey 
should be substituted. 

Attention must be paid to the quality of milk given to infants. There 
are many dairies in Xew York City which furnish an excellent quality of 
milk, owing to the great care bestowed upon the milk supply by the Health 
Department, and also by the Milk Commission. 

If milk seems to aggravate an attack of dyspepsia, then zoolak or 
kumyss or other fermented milk may be tried. Buttermilk is very nour- 
ishing and very useful in dyspepsia. Junket may also be tried: so also can 
whey be given several times a day. Soups and broths, calf's foot and chicken 
jellies are all nourishing. Steak juice and unfermented grape juice will 



ACUTE GASTRIC CATARRH. 247 

be serviceable. Boiled fruits, such as apples and peaches, if the child is old 
enough and the condition warrants it, may be tried. 

Our aim musi be to have the inlaid fed with a Large interval of rest, 
so that nausea and vomiting may be prevented, and in order that the food 
may be properly assimilated. We must therefore give small quantities with 
large feeding intervals. When the functions are again normal then we can 
return to a judicious, nutritious diet, as demanded by the infantile stomach. 
It is advisable to give mix vomica in doses of 1 minim for a child, 1 to 3 
years old, three times a day before feeding, and to continue the same for 
months after the gastritis disappears. The writer lias seen the most marked 
improvement following the use of this drug, and regards it as a specific for 
toning the stomach. 

Malt extract should be given in doses of a half teaspoonful, three times 
a day, to aid nutrition. It is well known that malt has a decided laxative 
effect. Care should be taken that fermentation is not reestablished while 
giving malt. In some cases it is not well borne in the commencement of an 
acute gastritis, and a total abstinence of milk and the substitution of boiled 
water, whey, soups, and broths may become necessary; very weak tea, to 
which the white of a raw egg has been added and sweetened with saccharine 
or with granulated sugar, can be given with advantage. 

Fever. — The temperature in the course of an acute gastritis requires 
no antipyretic treatment, although sponging the surface or a cold pack, 
applied over the thorax and abdomen, will be serviceable. Specific fever 
treatment is uncalled for. The well-known depressing effect of antipyretic 
drugs must not be forgotten, and hence the specific cause of the disease 
must be removed. This is usually stagnant food. The same requires clean- 
ing out with calomel or cascara. The cause of the fever will be removed 
with such effectual treatment. 

When children have a tendency to convulsions then a mustard foot- 
hath can be given and an ice-bag applied over the anterior fontanel, or 
at the nape of the neck. In such instances the most rapid treatment will 
he called for, such as washing the stomach with a catheter, using warm salt 
water. An emetic will prove useful in those cases where lavage cannot be 
successfully carried out. 

Alcoholic stimulation is contraindicated in every form of gastric fever. 
The writer has always seen bad results follow the use of whisky when the 
gastric mucous membrane was inflamed. If, however, the patient is threat- 
ened with collapse, or the pulse is very weak, then small doses of musk in 
the form of a tincture of musk can be injected hypodermically, every hour, 
until the pulse-rate improves. Camphorated oil, injected hypodermically. in 
doses of from 5 to 15 minims, may do good in some cases. 

Hot coffee may be given in small doses, two or three teaspoonfuls 
repeated every fifteen minutes, until its physiological effect is manifested. 



248 DISEASES OF THE STOMACH. 



Pyloric Obstruction Caused by Spasm of the Pylorus. - 

Tlie symptoms of obstruction of the pylorus, due to spasm or obstruc- 
tion due to hypertrophy, are strikingly similar. It is difficult to differen- 
tiate the fame in many cases. In the one, the spasm is a benign condition 
which yields to and is frequently overcome by mild and palliative remedies. 
In stenosis, however, we have a serious condition and one that has cost many 
lives, despite proper surgical measures. 

Causes. — The most frequent cause of pyloric spasm in infancy is due 
to irritating food, that is. food containing excessive high fat and high 
proteids. Another cause of pyloric irritation resulting in spasm is seen 
when human milk is suddenly withdrawn and cows'' milk substituted. "When 
there is deficient peptic secretion, including hyperacidity, such condition as 
spasm may be caused by stagnation of the gastric contents. 

Common Symptoms. — The most noteworthy symptom in this condition 
is vomiting or regurgitation. Said vomiting will follow soon after food 
reaches the stomach. In some cases all of the food partaken will be 
ejected; in other cases small quantities will be vomited at intervals. On 
placing the infant in the dorsal position antiperistaltic waves can be noted 
by inspecting the abdomen. These waves are seen after food is taken. 
These worm-like movements disappear when the stomach is empty. From 
the loss of food and improper nutrition there naturally results loss of 
weight. When the spasm yields, the food will pass into the duodenum, and 
resulting therefrom there will be more or less faeces evident. If, therefore, 
stool is noted, then spasm of the pylorus and not stenosis exists. 

Pyloric Stenosis. — When an obstruction due to a pyloric hypertrophy 
and stenosis exists, there results usually a dilatation of the stomach from 
the stagnation of the gastric contents. The evacuations following colonic 
flushing will bring away some jelly-like or greenish masses, but milk 
faeces will not be found. This is an important diagnostic point and will 
differentiate the spasmodic from the stenosed condition. 

Diagnostic Aid. — A small metallic bucket, devised by Einhorn. some- 
what smaller than an ordinary sized pea, is fastened to a white silk cord. 

This bucket is introduced into the stomach by placing it on the tongue 
and feediug the infant a bottle of water or food. The infant swallows the 
bucket and the same is allowed to remain in the stomach over night. When 
pyloric stenosis is present the bucket remains in the stomach. If. however, 
there is no stenosis the bucket will pass into the duodenum, and the bile- 
stained string will show the probable depth that the bucket entered the 
duodenum. 

The following cases will give an idea of the length of the cord re- 
quired at various ages : — 



PYLORIC OBSTRUCTION. 



249 



Name. 


Age. 




Weight. 


From Mouth 

to Oardia. 


From Mouth 
to Pylorus. 


Total 
Length. 


Baby K. 


8 nu»s. 




8 lbs. 10 ozs. 


11 cm. 


16 cm. 


22 cm. 


Baby R. 




2 wks. 


7 lbs. ( .) ozs. 


14 cm. 


20 cm. 


24 cm. 


Baby B. 


2 mos. 


2 wks. 


6 lbs. 1 oz. 


12 cm. 


17 cm. 


21 cm. 


Bafcy K. 


4 mos. 




11 lbs. 14 ozs. 


16 cm. 


21 cm. 


27 cm. 


Baby A. 


10 mos. 




11 lbs. 12 ozs. 


10 cm. 


24 cm. 


30 cm. 



1 choose the evening feeding time or about 6 p.m. as the best time for 
introducing the bucket, then give the infant the regular feeding, and with 
very few exceptions the same was retained. If, however, the bucket was 

expelled by vomiting it was reintroduced at the next feeding. To be sure 
that no obstruction to the duodenum existed, I left the bucket in over 




Fig. 65a.— Infantile Duodenal Bucket with Syringe attached, to Aspirate Bile. 

night. On withdrawing the same after about twelve hours, a yellowish 
bile-stain from the duodenal bucket for at least 8 to 10 centimeters will be 
noted on the cord. In pyloric obstruction, however, no bile-stain was noted. 

By this method of diagnosis we can learn whether or no pyloric 
stenosis is present. It is an important aid if surgical relief is demanded. 

Instead of a cord, a thin rubber tubing attached to and ending in a 
perforated bucket can be passed into the stomach, and by leaving it there 
several hours the bucket will pass through into the duodenum. By means 
of a little glass syringe, I was enabled to aspirate bile, in some cases a 
greenish, in other cases a yellowish fluid, alkaline in reaction and of 
viscid consistency. 

There are three ferments for which a test can be made. They are: (a) 
steapsin, (b) trypsin, (c) amylopsin. 

' (a) To test for trypsin, I use 1 drop of neutral milk, 2 drops of water, 
2 or 3 drops of duodenal contents (neutralized if the reaction is acid), and 
a small piece of blue litmus agar. This is placed into a miniature test 
tube and kept at blood temperature. If steapsin is present the agar will be 
red in twenty to thirty minutes, owing to the development of fatty acids. 



250 DISEASES OF THE STOMACH. 

(b) For the demonstration of trypsin I use a small piece of the white 
of a hard-boiled egg, which is placed in the fluid to be examined (if acid, it 
is first neutralized) and kept a few hours at blood temperature. The piece 
of egg albumin disappears in the presence of trypsin. The ricin test used 
for pepsin is unsuitable for trypsin. If we add ricin solution to duodenal 
contents and leave it at blood temperature for a few hours, and then add 
hydrochloric acid or acetic acid, the ricin will often be precipitated, i.e., it 
will not be changed into soluble peptone. 

(c) Amylopsin. In testing for the presence of diastase we make use 
of a boiled starch solution or starch paper. We mix the duodenal contents 
with the starch solution (in equal parts), or insert a strip of starch test 
paper and leave it at blood temperature for one-half to one hour, adding a 
weak soluticn of iodine. Starch, if present, gives a blue color, and erythro- 
dextrin a red color; otherwise only a trace of brown from the iodine. 

Hypertrophic Pyloric Stenosis. 

This condition is not so rare in infancy as is commonly supposed. 
While in 1902 Cautley and Dent reported 109 cases, we have since then 
over 150 cases recorded in medical literature. 

Etiology. — Stenosis may occur as a congenital malformation. Hyper- 
acidity is believed to be responsible for some cases of spasm of the pylorus 
resulting in hypertrophy. Thomson believes that by the ingestion of liquor 
amnii in iutra-uterine life both the stomach and pylorus are excited to over- 
action, due to the presence of this irritant fluid. 

Morbid Anatomy. — Under normal conditions the circular muscle fibers 
of the pylorus at birth are relatively augmented, gradually approaching the 
normal as the long axis of the stomach assumes its horizontal direction from 
the vertical ; this relative augmentation of the circular fibers is intended 
to prevent the too rapid emptying of the vertical tubular infantile stomach 
during the first two weeks of life. These fibers, stimulated to excessive 
function by any given cause, must, according to recognized physiological 
principles, become hypertrophied. 

Accepting such a working basis, we should recognize in hypertrophic 
pyloric stenosis the ultimate results of a pathological process whose first 
stage is represented by an excessive functional activity of the pyloric muscu- 
lature; its second stage by hypertrophy and spasm of this musculature, and 
the third stage by a general overgrowth of the normal constituents of the 
involved parts. 

Symptoms. — There is a sudden onset of symptoms. The food will 
suddenly disagree. There are active peristaltic and antiperistaltic waves 
visible. This is most marked after the infant has swallowed food or water. 
In a case reported by me very strong peristaltic waves could be noticed 



HYPERTROPHIC PYLORIC STENOSIS, 251 

from left to right. 1 There was a distinct hourglass contraction, the stomach 
bulging on either side with a sulcus in the middle. The abdominal walls 
are lax. The intestinal wall, chiefly the transverse colon, can be easily 
mapped out. 

On palpating the pylorus in my own cast", a hard, resisting mass about 
the size of an adult's thumb could be felt. Gradual emaciation from inani- 
tion will be Doted. 

Stagnation of the gastric contents is proven by the fact that, while 
two ounces of the food are swallowed, six or eight ounces arc frequently 
regurgitated and vomited. The quantity of urine is also scant, owing to the 
small quantity of liquid and food absorbed. A whole day will frequently 
pass without a single diaper being wet. 

The examination of the gastric contents shows great variability. In 
my own case, the presence of lactic acid and the total absence of hydro- 
chloric acid were noted. Other observers have noted an excess of hydro- 
chloric acid. 

Prognosis. — If the vomiting persists, death will occur from exhaustion. 
1 n a ease seen by me, where operation was refused, the infant died of inani- 
tion after three weeks. 

Treatment. — Dilute the food to half-strength. If a milk mixture con- 
taining 2 per cent, of fat has been given, then 1 per cent, should be tried. 

There should be a longer interval between the feedings. If a baby 
has been fed every two hours, it should be fed once in three hours. If two 
ounces had been given at one feeding, then one ounce should be tried. If. 
after this method, vomiting persists, then the stomach should be allowed to 
rest at least twenty-four hours, during which time rectal feeding can be 
tried. Stomach-washing every morning with normal saline solution may do 
good in some cases. 

On the theory that hyperacidity caused pyloric spasm, Knoepfelmacher 
used whole milk feedings to modify the hyperacidity. Bromide of sodium, 
codeine, menthol, or subnitrate of bismuth may be tried. 

Surgical Treatment.— -If, after a patient trial of the above-outlined 
plan, the condition does not improve, then surgical relief is indicated. In 
this stenotic stage, gastro-duodenostomy in two sittings, if necessary, should 
be the operation of choice. 

"At the first of these, slight fixation of the involved parts to the abdomi- 
nal incision, opening of the duodenum, and the insertion of a temporary 
catheter for purposes of direct feeding. 

"After a proper interval, depending upon the patient's gain in nutrition 
and strength, an anastomosis between this opening in the duodenum and 
the stomach, either by the small button of Meyer or a modification of the 
Finney operation."' (Sturmdorf.) 



1 Archives of Pediatrics, May, 1906. 



252 DISEASES OE THE STOMACH. 

Post-operative Treatment. — Strychnine, \ 150 grain hypodermic-ally 
every three hours, is required. Xorraal saline injections, either by high 
colonic flushing. or, if the pulse is weak, by means of hypoderrnoclysis. 

By mouth, several teaspoonfuls of whey every hour. This method is 
ample for the first few days, after which special feeding rules may be in- 
dicated. 

Gastro-duodexitis (Catarrhal Jaundice). 

"When the infection of an acute catarrhal gastritis extends into the duo- 
denum, jaundice usually results. This is due to an involvement of the 
common bile ducts. 

Symptoms and Diagnosis. — Yellowish pigmentation of the skin and con- 
junctival mucous membrane are noted. The urine is brown or deep yellow. 
The stool is whitish or clay-colored. The temperature ranges between 
100° and 103° F. Anorexia and thirst usually exist. Nausea or vomiting 
may occur. The pulse is full and regular. The liver is usually enlarged. 

Treatment. — Elaterine or podophyllin in ^ grain doses, repeated, if 
necessary, in three hours, or phosphate of soda, 10 to 20 grain doses every 
three hours, until liquid stools are produced. Dilute nitro-muriatic acid, 
2 to 5 drops may be given twice a day. Liquid food, such as thin soups, 
diluted milk or skim-milk or buttermilk, and fruit juices, for thirst. 

Chroxic Gastritis (Chroxic Glaxdular Gastritis — Chroxic 

Yoalttixg). 

This is a chronic inflammatory disease affecting the gastric mucous 
membrane. The functions of the stomach are disturbed owing to the large 
quantities of alkaline mucus being secreted. There is a distinct loss of 
tone in the gastric mucosa. Large quantities of food will frequently stag- 
nate, causing fermentation and vomiting. 

Pathology. — The changes in chronic gastritis, seen post-mortem, are 
similar to those met with in the acute form. There is a degeneration of the 
epithelium of the gastric tubules. Frequently there is dilatation of the 
stomach. 

Microscopically the glands often seem enlarged, sacculated, and dilated 
in cyst-like forms. Ewald states that there is a mucoid degeneration. 
When there is a total destruction of the glandular layer of the entire organ, 
we have an atrophic condition which Ewald calls anadenia ventriculi. 

Symptoms. — Vomiting is a prominent symptom. Large quantities of 
sour or bile-stained mucus are ejected. At other times sour-smelling liquid 
containing particles of food is ejected. Farinaceous foods cause particular 
distress. Pains referred to the abdomen are complained of. and the abdo- 
men is usually distended and tender on palpation. The tongue is coated. 



I HRONN GASTRITIS. 253 

Tlio papillae are enlarged and the edges and tip are of a bright glazed red. 
Eructations of gas are frequently ooted, especially alter feeding. 

The Bowels. — Constipation alternates with diarrhoea in this condition. 
We find a child will suffer with constipation for three or lour days, and for 

no apparent reason a diarrhoea will appear and continue for a week or 
more. Eczema is usually associated witli this condition. There is usually 
anorexia. Owing to the malnutrition, such children appear underfed and 
seem to he anaemic. They emaciate from loss of sleep in addition to the 
continued vomiting. Their extremities are usually cold, owing to a poor 
circulation. Headache is a prominent symptom in children old enough to 
complain. The clinical picture is such that one must take extreme care 
to make a proper diagnosis. Frequently there is a hacking cough present. 
We may exclude tuherculosis if the pulmonary signs are wanting in addi- 
tion fo the absence of the tubercle bacillus. 

Diagnosis. — The diagnosis is easily made if we remember that tuber- 
culosis has fever which at times assumes a hectic form. We have previously 
mentioned the necessity of rinding the tubercle bacillus if tuberculosis is 
suspected. Typhoid fever is so different that we can easily exclude this by 
resorting to the Widal and diazo reactions. Syphilis, if suspected, will 
respond to 'specific treatment. 

Prognosis and Course. — This condition should be looked upon as every 
other chronic disease in which vitality, surroundings, and proper care play 
an important part. If a child of a poor family living in a tenement house 
suffers with this chronic disease, the outcome will be different than if the 
child were living in the country, where fresh air could and would stimulate 
metabolism. Earely is this condition fatal, although with extreme emacia- 
tion and continued vomiting inanition may cause death. 

Treatment. — Dietetic Treatment: This is the most important factor. 
The feeding interval should be extended so that the child should be fed 
less often than formerly. The quantity of food should be reduced so that 
the stomach receives less work. By all means give food that is easily as- 
similated. In some cases nothing but predigested food or peptonized milk 
will be retained. Each child should receive a carefully prepared diet list, 
and we must insist on strict rules. Give older children soups, broths, albu- 
min, such as white of egg. and peptonized yolk of egg. Give infants diluted 
milk or one of the infant foods temporarily. When vomiting persists and 
apparently little or no food is retained, it is advisable to put the child to 
bed and resort to rectal feeding for two or tnree days. This is one of 
the best means of allaying gastric irritability. (See chapter on "Keetal 
Feeding.") 

Hygiene. — Without fresh air, active exercise, such as walking, or 
passive movements such as massage or gymnastics, we must expect little 
or no benefit. Daily sponging or bathing, followed by friction with a coarse 
towel, will stimulate the circulation. 



254 



DISEASES OF THE STOMACH. 



Medication. — Stomach washing, by using 1 or 2 pints of warm water 
to which bicarbonate of soda has been added, is very useful. This may be 
repeated every day. Sodium phosphate, in 5- to 10- grain doses, every morn- 
ing or evening, is indicated. 

Fowler's solution, in 1- to 5- drop doses, three times a day. and mix 
vomica, in 1-minim doses, three times a day. 1 

Bismuth subnitrate or bismuth beta-naphthol, to relieve the diarrhoea, 
are very valuable remedies. 

For persistent vomiting menthol, in 1-grain doses, and oxalate of 
cerium, in 2- or 3- grain doses, every few hours, are useful. Gentle currents 
of faradic electricitv will also aid and strengthen the atonic condition. 



Acute Dilatatiox of the Stoviach. 

This condition is quite frequently met with in children. 
Etiology. — The anatomical and physiological peculiarities of the in- 
fantile stomach render it peculiarly susceptible to the development of this 




Fig. 66. — Drawing from a Case of Acute Dilatation of the Stomach. 
Giving Exact Size Post-mortem. Bottle-fed Infant. Summer Complaint, 
Due to Over-feeding, and Too Frequent Feeding. Compare normal size with 
the dilated condition. (Original.) 



1 Fraser. of Xew York City, makes 
-oluble and quite palatable. 



a 1-minim mix vomica tablet, which i: 



BULIMIA. 

condition. The walls of the stomach are thin. The weakness of the re- 
sistance of the muscular wails and the ease with which a general a mem i a 
and resultant muscular atony occur in children must be remembered in 
considering etiological factors. Rachitis plays an important part in the 
development of this condition. Severe gastric catarrh with associated 
fermentative conditions are predisposing factors. 

Pathology. — A general atrophied condition of the entire gastric wall 
rts. The muscular coats are frequently thickened. The mucous mem- 
brane shows evidences of chronic catarrh. This condition is usually seen 
in marasmic or rachitic children. The stomach is invariably dilated. 

The symptoms of this condition correspond to those of chronic gastric 
catarrh. In standing the child upright the contour of the greater curvature 
of the stomach can be made out if emaciation exi- niting is a promi- 

nent symptom, a sour, frothy liquid being thrown up. Suecussion is fre- 
quently heard, but cannot be depended on as a positive symptom in this 
condition. Children suffering with acute dilatation usually have a very 
good appetite. They always show evidences of malnutrition. The results 
of percussion are very misleading. A tympanitic sound may be heard when 
the child is on its back. It may also be absent. Henoch states that severe 
dilatation of the stomach in a child may cause dyspncea. It may also dis- 
place the heart if dilatation is severe. 

Diagnosis. — The diagnosis can usually be made by the symptoms above 
described. It is important to remember that a dilatation of the colon may 

- :: :.r ~::~t :::-r : i: - :". - " := -.--;- rim '--:-■--:■■■.■. \il . z : : 

colon and dilatation of the stomach can be made by artificially distending 
the stomach with the aid of a Seidlitz powder. Translnmination of the 
stomach with the aid of a gastrodiaphane will aid in mapping out the 
anatomical outlines of the stomach. 

Prognosis. — This depends on the condition of the child when treat- 
ment is commenced. If the child is physically debilitated and does not 
assimilate food, the prognosis is grave. It is safest to give a cautious 
prognosis in every case 

Treatment. — Semi-solid foods should be given, if possible, and large 
quantities of liquids avoided. The normal tone of the stomach can best be 
restored by the administration of nux vomica and iron in suitable doses. 
The value of electricity and massage must be remembered. They will 
e the tone of the stomach when judiciously used. Specific conditions 
such as rickets and syphilis, if present, require their proper treatment. 



Bulimia (Abnormal Appft: 

Constant desire to eat is frequently seen when intestinal parasites, such 
«eworn>. are present. so found as a svmptom of hvsteria. 



256 



DISEASES OF THE STOMACH. 



A. T>., 7 years old, desired five and six meals a day. Her body was emaciated 
and occasional abdominal pains were described. The mother attributed the pains to 
overeating. After several doses of filix mas a tapeworm was dislodged (see treat- 
ment in the chapter on "Tapeworm" ) and the bulimia disappeared. 

Gastroptosis (Descensus Ventbiculi), Low Position of 
the Stomach. 

We are indebted to G-lenard 1 for emphasizing sufficiently the clinical 
symptoms due to this condition. 

Etiology. — Tn subnormal conditions such as chlorosis or where a gen- 
eral atony exists, a weakening of the ligaments takes place and the abdom- 




Fig. 67. — Transamination of the Stomach with the Aid of a Gastro- 
diaphane, in a Case of Gastroptosis. 'Original.) 

inal viscera consequently descends. Very tight lacing is frequently a cause 
in young girls. 

In a series of autopsies made by Glenard he found the transverse colon 
displaced and stenosed. 2 

Symptoms. — A variety of nervous symptoms such as irritability, head- 
ache, restlessness by day and insomnia by night, is frequently due to this 
disorder. The symptoms which characterize nervous dyspepsia in the adult 
correspond with the train of symptoms noted in this condition. Constipa- 
tion is usually present: there are loss of appetite and eructations. 



1 Lyon medicale, 1885, p. 450. 

2 Emhorn: •'Diseases of the Stomach," First Edition, p. 368. 



GASTROPTOSIS. 



25" 



Diagnosis. — Ewald advises inflation of the stomach as the best means 
of diagnosis. "When the stomach is inflated the lesser curvature, in cases 
of gastroptosis, is visible midway between the ensiform process and the 
navel, or just in the neighborhood of the umbilicus." With the aid of the 
gastrodiaphane we can transluminate the stomach and make out the contour 
of the same. This has been found a valuable means of diagnosis. The red 
illuminated area can be plainly made out if the room is darkened. The 
following ease illustrates this condition as met with in practice : — 

llosie B. was first seen by me when 13 years old. 

Family History. — Father and mother living and well. She has six sisters and 
one brother living, all in good health. There is no family history of syphilis, rheuma- 
tism, or tuberculosis. One child of 3 years died from pneumonia complicating measles. 

Personal History. — She was a breast-fed child and appeared to be well de- 
veloped. She has had measles and with it bronchitis. Menstruation appeared when 
she was 13 years old and lasted seven days. She has complained for the last two 

b 




Fig. OS. — (a) Normal Position of Stomach, {b) Position of Stomach in a 
Case of Gastroptosis. (Original.) 

years of headaches, pains in the back and abdomen, loss of appetite, and does not 
sleep well. She is very nervous and has had a peculiar unilateral twitching in- 
volving the right arm and shoulder. This twitching appears spasmodically and is 
exaggerated when her attention is directed to it. She complains of cold extremi- 
ties, and has an occasional cough. No expectoration. The cough appears to be 
of the same character as that seen in adults which is described as a hysterical cough. 
The chemical examination 1 of the gastric contents syphoned off one hour after 
feeding a test meal of tea and zwieback gave the following: 25 cubic centimeters 
obtained, color greenish yellow, very tenacious, ptyalin present in saliva. Reaction 
of gastric juice acid, no free hydrochloric present, lactic acid absent, peptones 
present, sugar present, starch present, combined hydrochloric acid present, estimated 
by titration equals 0.02 per cent, hydrochloric acid. A splashing sound could be made 
out on the left side of the abdomen in the area bounded by the umbilicus or above 
it to the symphysis pubis. With the aid of the gastrodiaphane the outline of the 
stomach could be plainly seen extending below the umbilicus. In the accompany- 
ing illustration (Fig. 68) the position of the stomach is outlined. 

X I am indebted to Mr. La Wall, chemist, for this analysis. 

17 



258 DISEASES OF THE STOMACH 

Prognosis and Course. — A displaced organ is not easily replaced by 
giving drugs or by mechanical treatment. The physician should inform 
the patient's relatives regarding the true condition. The life of the child 
is not necessarily endangered by the displaced stomach, yet the abnormality 
should be treated on the principle of general building up of the entire sys- 
tem with special reference to the diet. 

Treatment. — The treatment of these cases consists in building up the 
system with the aid of electricity, massage, and general restorative treat- 
ment; cold sponging with brisk friction of the surface of the body to 
stimulate the circulation; also, light bodily gymnastics. Nux vomica or 
its alkaloid, strychnine, should be given for a long time. 

A tight fitting abdominal bandage has frequently relieved acute symp- 
toms. Boas, of Berlin; Einhorn, Kemp, and Eose, of New York, are 
among those who advocate supporting the abdominal muscles by this 
mechanical device. 

Surgical Treatment. — When no relief is obtained by the abdominal 
supporter or bandage previously referred to, then surgery may be demanded. 
Some surgeons advise supporting the stomach by means of stitching the 
omentum to the abdominal peritoneum. By this means we have "a method 
of suspending the stomach in a hammock made by the great omentum.*' 

Ulcer of the Stomach. 

Gastric ulcer is frequently seen in chlorotic girls. It is usually the 
result of living in unsanitary surroundings, or when the body is reduced 
to a subnormal condition. Young girls at or about the period of menstrua- 
tion that are sent to work in factories or shops, who cannot take proper 
time for their meals, are occasionally seen with evidences of gastric ulcer. 
In most cases the ulcer is simply a continuation of a chronic catarrh of the 
gastric mucous membrane which has laid the foundation for this condition. 

Symptoms. — Pain in the stomach which is distinctly localized and can 
bp pointed to in the same area. The pain increases after taking solid food, 
although pain is also noted when any liquid enters the stomach. At times 
bright red blood will be expectorated, although the blood may be very dark 
in color. There is also a tender area usually localized between the ninth 
and tenth dorsal vertebrae which is marked on palpation. 

Diagnosis. — The positive diagnosis should only be made after a chem- 
ical examination of the gastric contents is made. The test meal and the 
method of examination is described in Part XII, page 915 to which the 
reader is referred. If an excess of HC1 is found in addition to the sub- 
jective symptoms of pain, the diagnosis of gastric ulcer is positive. 

The following case of gastric ulcer was presented by me before the 
New York County Medical Association, May 15, 1899 :— 



CYCLIC VOMITING. 259 

Marv I 1 ... 13 years old, complained of headaches and general weakness. She 
was emaciated and had anorexia, she had Buffered with constipation, dizziness, 
Dausea, and vomiting. Her heart's action was irregular. For four years she 
complained of pain in the middle of the stomach which was always Localized in 
tin- same area. The gastric pains were strongest after partaking of solid food. 
She had pain whenever any food, solid or liquid, was swallowed. The pain is 
described as a burning pain. She has a tender area between the ninth and tenth 
dorsal vertebras. This tenderness is marked on palpation. Three years ago she 
had an attack of hsematemesis, but none since then. The gastric contents were 
examined after a test meal, and an excess of HC1 was found. Owing to the 
danger of traumatism I thought it best not to repeat the syphoning off of the 
gastric contents, as there was a risk in repeating the haemorrhage. There was no 
evidence of hysteria in the case. The diagnosis of gastric ulcer was made. 

Treatment. — Liquid diet, rest in bed. and bismuth gave quite some relief. 
When solid food was tried the gastric pain returned. 

Prognosis and Course. — Great care should be taken before giving a 
positive opinion concerning the outcome of gastric ulcer. If the condi- 
tions that induced the disease can be modified, then a chance for recovery 
exists. These cases, as a rule, do badly unless placed under the strictest 
supervision of a trained nurse. Such cases require treatment in bed, rather 
than ambulant treatment. Years of patient treatment may be required 
before positive benefit is secured. 

The prognosis depends on the above conditions. The disease is chronic 
and may cause death. 

Treatment. — Such cases do well by having a change of air. These 
children should not be permitted to attend school, and the same applies to 
the workshop, if the child is working. Sea bathing and cold sponging of 
the body, followed by friction, is very beneficial. A rigid liquid diet, con- 
sisting of peptonized milk, zoolak. soup, broth, and strained gruel, with an 
occasional change to cocoa, should be allowed. Fruit may also be permitted. 
Tli is treatment must usually be carried out for months before recovery may 
be expected. 

Cyclic Vomiting. 

A great many writers report attacks of vomiting occurring at irregular 
or regular intervals of weeks or months which are termed cyclic vomiting. 
They claim that these attacks are not dependent on acute gastric disturb- 
ances, but are simply explosives due to latent or possibly nervous conditions. 
I cannot agree to the above statement, as in all cases seen by me in which 
recurring vomiting took place I could always trace some dietetic error or 
some auto-intoxication as an exciting factor of the vomiting. Joseph Win- 
ters, an authority on pediatrics, ridicules the above condition. 



DISEASES OF THE STOMACH. 



I yspepti Asthma. 

Peripheral irritation of the terminal filaments of the pnenmogastric 
nerve frequently causes dyspeptic symptoms which result in asthmatic 
attacks similar to those found in adults. A ise of this kind came under 
my care in which fermentative conditions in the stomach caused pressure 
on the diaphragm and gave rise : sthmatie atta<: fo 

A well-nourished boy. 9 years old. was referred to me by Dr. H. Jarecky. He 
had attacks of coughing, wheezing, and slight cyanosis. The hands and feet were 
cold. The tongue was coated: the stomach distended with gas and very tympanitic 
on percussion. The asthmatic attacks were caused by the distention and p: 
on the diaphragm, and disappeared when a rigid diet and a laxative were given. 
The bov suffered in addition with rheumatism. 



CHAPTER TV. 

DISEASES OF THE INTESTINES. 

The Abdomen. 

The abdomen of a child is comparatively larger than that of the adult. 
Especial attention should be given to the condition of the abdomen; for 
instance, a retracted abdomen is usually seen in meningitis. (See chapter 
on "Meningitis.") A distended abdomen is frequently seen in rachitis 
(pot-belly). (See chapter on "Rachitis.") A very prominent abdomen is 
seen in chronic peritonitis, to which I direct attention in the special chapter 
dealing with this subject. 

The Intestines. 

Small Intestine. — At birth the length of the small intestine is nine and 
one-half feet. The length of the intestine may, however, vary with the size 
of the child. In the duodenum Brunner's glands are found. Below the 
duodenum Peyer's patches are found. The most important physiological 
function of the small intestine consists in aiding the assimilation of food 
by the action of the pancreatic juice and other secretions. The emulsifica- 
tion of the fat in the food takes place in the small intestine. 

Length of the Intestine. — The relative length of the intestines in nurs- 
lings is greater than in adults, so that the intestines are six times as long as 
the body. Forster believes this is one reason why nurslings receive more 
nourishment from milk than do adults. The small intestine develops during 
the first two months of life more than the large intestine, and after the 
second month the reverse is true. The duodenum remains relatively the 
longer until the end of the fourth month. The transverse colon is the widest 
and most elastic portion of the large intestine. The continuation of the 
large intestine in infants, into the rectum, is indicated by a narrowing at 
this point. 

Large Intestine. — According to Treves the large intestine measures: — 

At birth 1 foot 10 inches, or 55 centimeters 

At 12 months 2 feet 6 inches, or 76 centimeters 

At 6 years 3 feet, or 91.5 centimeters 

At 13 years 3 feet 6 inches, or 107 centimeters 

Course of the Colon. — From the right iliac fossa up to the liver, then 
transversely across the abdomen to the spleen and then downward, ter- 
minating in the rectum. The colon forms at its first turn the hepatic 
flexure, at the spleen the splenic flexure, and finally the sigmoid flexure. 
The curve of the sigmoid flexure occurs in the left iliac fossa. 

(261) 



262 DISEASES OF THE INTESTINES. 

Sigmoid Flexure. — The anatomical illustrations of the sigmoid flexure 
(see chapter on "Chronic Constipation") are important to remember in 
view of the mechanical cause of constipation so frequently seen in young 
children. 

The transverse colon, when distended with gas, is very easily mapped 
out by percussion. 

The Caecum. — Dwight found the caecum completely covered with peri- 
toneum in 33 out of 3T cases in young children. Treves states that in 100 
cases observed by him he found the peritoneum infolding the caecum in 
all of these cases on its posterior surface. 

The caecum occupies a higher position anatomically in a child than 
in adult life. 

Vermiform Appendix. — Behind the caecum lies the vermiform appendix. 
It is important to remember that it lies in the line midway between the 
umbilicus and the crest of the ilium. When the appendix is inflamed and 
swollen it can frequentlv be manped out by rectoabdominal (bimanual) 
palpation. 

Formation of Gas in the Intestine. — AVhen we consider the lesser 
development of the muscles of the intestine, we can readily understand 
that peristaltic movements are more irregular and less forcible, and that 
the muscles possess less tone; on this account there is a larger amount of 
gas contained in the intestine, which constantly distends it. Thus it is 
apparent why the abdomen always appears larger in the infant in propor- 
tion to the other parts of the body. 

Action of Intestinal Muscles. — The action of the intestinal muscles is 
chiefly to transport the food by a series of peristaltic movements. Parts 
of the intestine are active, while others remain passive. Heubner maintains 
that post-mortem examinations never show all parts of the intestine in the 
same condition, owing to the irregularity of the muscular movement. 

Development of Glandular System. — The development of the glandular 
system in infants is very poor, whereas the lymphoid tissues and follicles 
are comparatively well developed. 

Lieberkiihn's glands are fewer in number than in adults, whereas the 
Brunner glands in the duodenum are numerous and well developed. 

The Secretory and Absorbing' Power of the Epithelium and the Glands. 
— Heubner maintains that the secretion takes place from cells, located in 
the small intestine, which are scattered about and are few in number, 
whereas in the large intestine thev are far more numerous. 

Absorption of Fat. — The absorption of fat takes place through the 
intestinal epithelium in the duodenum and jejunum ; the glands also par- 
ticipate in this action. According to the histological investigations by 
Baginsky, the real absorbing system of the intestinal wall is found in the 
connective-tissue bodies of the mucous membrane of the infantile intestine. 



STOOLS. 



263 



in which are located lymphatic vessels connected with the larger Lymph- 
channels of the intestine. The physiological and chemical functions are 
mnch less developed in infants than in adult- because the intestinal -lands 
are relatively less developed. 

Infant Stools. 

Meconium.— The first discharge from an infant's bowels is called 
meconium. It has a greenish-brown color; at times it resembles ink in 
color. It is composed of epithelial cells, bile, cholesterin crystals, and 
partly digested amniotic fluid. Meconium has no odor. It is usually acid in 
reaction. The color of the infant's stool changes after a few days of ma- 
ternal or bottle feeding. 

As soon as the exclusive milk diet is changed to the mixed diet we then 
lose the characteristic infantile stool, and it resembles more that of an adult, 
though remaining softer and thinner throughout infancy. The stools be- 
come darker in color, assume the adult odor, and have more varieties of 
bacteria than those previously mentioned as found in the stool of a milk 
diet. 

A new conception of the various food elements shows that the opinion 
of ten years ago regarding the dangers of high fat have been modified, and 
the possibility of a proteid or casein element being the disturbing factor 
suggested. Modem science has proven beyond a doubt that one reason why 
the fat element or casein disagrees is due to the presence of milk sugar; 
hence we today regard the carbohydrate and salt as the disturbing element 
in many cases, rather than the fat or casein. 

Finkelstein, of Berlin, has proven that in atrophic and marasmic 
infants in which there is a constant decomposition associated with fever and 
undigested stools we can modify the nutrition and restore faulty metabolism 
by omitting the additions of sugar or salt. The most important point, 
however, is that we can feed a very large fat and proteid food, such as casein 
milk, described in the chapter on Faulty Metabolism, without causing 
gastric disturbance. 

The stool of a nursling or an infant on a human breast should be 
yellowish in color, smeary or pasty-like in consistency, and have an acid 
reaction. Xormal yellow stool of a breast-fed infant contains bilirubin. 
Hydrobilirubin is associated with bilirubin after several weeks. 

Xot infrequently during the first three months, normal infants fed 
exclusively at the human breast will have several stools a day. They may 
be green, watery, contain mucus, or appear lumpy. Such infants thrive, 
gain in weight, sleep well, and are apparently healthy. The cause of such 
peculiar stool has not yet been determined. They may be caused by 
maternal influences. Such stools are more frequent whilst the mother is 
menstruating. These stools should by no means be regarded as due to a 



964 DISEASES OF THE INTESTINES. 

pathological condition, for we all can notice how this condition will 
regulate itself; even though greenish stools persist for several weeks, by no 
means should we change the food, but continue the breast if at all possible 
for the first three months. 

Reaction cf Stools. — Eeaction of stools in diarrheal disease and in 
health is chiefly acid, or, next in frequency, neutral. Alkaline stools are 
rare. Grass-green stools, usually acid, are seen in the early stage of 
dyspeptic diarrhoea. The color varies from a pale greenish-yellow to grass 
green owing to improper food. 

The reaction depends on the presence of lactic acid, the source of which 
is the milk sugar. The only gases present are H and C0 2 . According to 
Escherich, H 2 S and C H 4 , to which the odor of adult stool is due, are not 
present. There are no special albuminoids peculiar to woman's milk. 
Those existing in woman's milk seem to be entirely absorbed. Peptone 
exists in trifling amount. Sugar is not present. Pancreatic ferment is 
absent, and sometimes traces of pepsin have been found. Mucus is always 
present in considerable quantity; also columnar intestinal epithelium. 

In the stool of nurslings large quantities of lactate of lime can be 
found; so also we frequently find oxalate of lime, depending on the quan- 
tity of oxalate of lime ingested. Tfflemann has noted the presence of 
bilirubin crystals in the stools of nurslings, in perfect health. 

Quantity cf Faeces. — The quantity of faeces varies, but it has been 
found that 100 grams of milk food will produce about 3 grams of faeces, 
according to Baginsky. This is a vital point, but I have found it very 
difficult to determine, for in most cases the napkins of the infant are 
soiled with urine plus the faeces, thus adding to the gross weight. 

Green Stools. — The green color of stool is caused by an abnormal 
oxidation of bile-pigment in which bilirubin is changed into biliverdin by 
means of an oxidase. 

Typical green stools can be produced by giving an infant two or three 
grains of bicarbonate of soda ; the soda must be given for a few days. This 
explains Pfeifler's alkaline theory. Typical green stools can also be pro- 
duced by giving small or large doses of calomel. If. after having given 
bicarbonate of soda and produced green stools, we give diluted hydrochloric- 
acid in 5- to 10- drop doses, the yellow color will reappear in a few days. 
Ehubarb will also produce a yellow stool. 

Stools which are pale yellow when discharged, and which afterward 
become green, are often seen in disease. They may be themselves neutral 
or alkaline in reaction; this latter may, however, depend on the admixture 
of urine. An excess of bile may often cause very green stools. 

TVegscheider has shown that the green color is the result of preformed 
biliverdin. The condition in the intestine, upon which the transformation 



STOOLS. 



265 



of bilirubin into biliverdin depends, has been generally regarded as one of 
acid fermentation. 

PiViilVr's experiments 1 show this former opinion to be wrong. Ho 
found that none of the acids formed in such fermentation — lactic, acetic, 
butyric, propionic, etc. — added to yellow stools outside the body, turned. 
them green, but that they made them deeper yellow. But dilute alkaline 
solutions added to fresh yellow stools turned them green after an exposure 
of thirty to sixty minutes, and strong solutions turned them, first, brown; 
later, after exposure to air, intense green. 

Casein in high and low percentages has decided therapeutic properties. 
It increases the intestinal secretion which amounts to ahout one quart 
daily. It has an alkaline reaction; hence acts antagonistic to pathological 
acidity and thereby arrests fermentation. It is possible therefore to modify 
intestinal fermentation associated with putrefactive stools by omitting 
sugar and salt, reducing the fat, but chiefly by increasing the casein. 

When milk sugar is added in large quantities to food, it results in a 
primary irritation of the epithelium of the intestine, resulting in acid 
fermentation, and this latter prevents new epithelium from forming. When 
this carbohydrate element (milk sugar) is reduced the symptoms are 
immediately modified, and when the milk sugar is discontinued the casein 
lumps quickly disappear from the stool; iii addition thereto the stool 
assumes a more solid consistency. 

Casein Masses or White Curds. — The coarser lumps of casein or so- 
called casein curds will be described later on. The small casein curds 
consist chiefly of fat. Casein is not nearly as common an ingredient of 
faeces as is supposed. As far back as 1878 Widerhofer doubted that these 
masses were really casein, but believed them to be fat with epithelial 
remains. Adler maintains that it is wrong to call a substance casein be- 
cause it responds to heat, biuret, Heller, and other proteid reactions. 

Casein masses or casein lumps are frequently found in infants whose 
intestinal tract had been thoroughly emptied, and where the diet consisted 
of whey. It is well known that the casein masses consist chiefly of 
undigested remains of casein together with fatty acids and alkalies (Selter). 
When we recall that the nucleoproteids of the intestinal secretion and the 
nucleoalbumins of the bile give a similar reaction, even starvation food 
and watery discharges in enterocolitis where milk has been withheld for 
a number of days will also give a positive proteid reaction in the stool, due 
to casein masses. 

When milk is deprived of fat and casein, the result is whey, and if 
this whey is fed to an infant we frequently have casein curds in the stool. 
These curds consist of saponified fats and numerous bacteria. The proteid 
reaction does not come from casein, but from tin 1 intestinal secretion, 

1 "Yerdauung im Siiuglings-alter bei Krankhaften-Zustanden," Jahrbuch fur 
Kinderhoilkunde, B. 28, page lt>4. 



266 DISEASES OF THE INTESTINES 

whereas the fatty acids and saponified fats are due to the sugar in the 
whey. 

Intestinal experiments at Finkelstein"s clinic, reported by Meyer and 
Leopold, show that when the food contains a higher percentage of sugar 
than the infant can assimilate the result will be so-called casein masses in 
the stool. That this view is correct is proven by the fact that the moment 
the sugar element is reduced casein particles gradually disappear. This 
fact will be still more impressed when we note that with the reduction of 
the sugar we can increase the percentage of casein, thus showing a higher 
tolerance for casein, after we reduce the carbohydrate element. 

Proteids. — The proteids of milk are so thoroughly absorbed that only 
small traces of them can be found in the faeces. 

Albuminous decomposition and its products — tyrosin, indol, phenol, 
and skatol — are not found in milk faeces. But lactic acid, acetic acid, 
formic acid, and other fatty acids are present, causing the acid reaction. 
Von Jaksch found a saccharine ferment in the faeces of children. Baginsky 
found a peptonizing ferment also in infantile faeces. Escherich says : x "If 
albuminous decomposition with very foul offensive stools exists, albumins 
should be withheld from the diet and carbohydrates, such as dextrine foods, 
sugar, and milk, given. If acid fermentation is present with sour, but not- 
offensive stools, carbohydrates are to be withheld and an albuminous food 
such as animal broths, bouillon, peptones, etc.. given. In the decomposition 
of milk, the sugar of milk, and not the casein, is usually broken up/ 3 

Sugar. — If the sugar is too low. the gain in weight is apt to be slower 
than when furnished in proper amount. The symptoms indicating an 
excess of sugar are: colic or thin, green, very acid stools, sometimes causing 
irritation of the buttocks ; sometimes there is regurgitation of food and 
eructations of gas. 

Artificially fed children excrete hydrobilirubin constantly. Whitish 
stools are usually associated with atony, also with various types of mild 
dyspepsia. In dyspeptic stools we are apt to find undigested casein or 
saponified fats. Scrambled egg stools frequently contain particles of undi- 
gested casein and fat. 

Fat Diarrhoea. — This condition is primarily due to an imperfect func- 
tion of the bile as well as to the abnormal state of the pancreatic secretion. 
In such conditions as tuberculosis of the mesenteric glands and in severe 
enteric catarrh we are apt to find verv fatty stools. According to Biedert 
and Demme. who have devoted considerable study to this subject, in some 
children the faeces showed 50 to 60 per cent, of fat. whereas the normal 
percentage in ordinary faeces varied from IT to 2b per cent, (which is the 
normal quantity according to "Tfnemann). 



1 Jahrbuch fur Kinderheilkunde. "BeitrSge zur Ami sept isclien BeliandHing- 
sinethode der Magen-Darinkranklieiten des Sauglmgsalters/' 



STOOLS. 267 

Excess of fat is Indicated by the frequent regurgitation of food in 
small quantities, usually one or two hours after feeding. Sometimes an 
excess of fai causes very frequenl stool Dearly normal in appearance. In 

come cases the stools contain small round lumps somewhat; resembling 
casein, but really masses of fat. 

Blood in Stools. — Blood from the stomach or small intestine frequently 
gives the stool a black color resembling tar. Thus, a practical point in 
Boas's "Diagnostik der Magen- und Darmkrankheiten" is that, the brighter 
the color of the blood, the lower down near the rectum and anus must the 
pathological lesion be looked for; the darker the blood, the higher up must 
the cause be sought; e.g., the diseased condition exists in the stomach, 
duodenum, or jejunum, etc., if the stool ontain black blood. If the 
corpuscular elements of the blood are wanting, then only the presence of 
blood can be positively diagnosticated by either a microchemical examina- 
tion or by means of the spectroscope. The presence of red blood-corpuscles 
must always be regarded as a pathological factor. 

Brown Stools, Muddy Stools. — A brown stool in an infant is frequently 
caused by a diet of animal food or by a diet principally of broth. These 
stools have no distinct consistency nor reaction. In dyspeptic diarrhoea or 
in some forms of enterocolitis w T e have very offensive stools and they 
resemble muddy water; with the latter there is considerable flatus during 
each movement. Brown stools may be due to changed biliary pigment and 
to drugs : e.g., bismuth causes the well-known dark stool. So also tannic 
acid and all iron salts give the dark stool, which varies from a deep 
brown to a black color. 

Mucus. — Mucus is always present in all healthy stools and is so well 
mixed with the stool that it does not appear as mucus to the naked eye. 
Any appearance, therefore, of mucus easily visible should be regarded as 
abnormal. Mucus is present in every form of intestinal disease : very 
abundant in inflammatory conditions affecting the large intestine, more so 
than in those affections of the small intestine, and especially so in inflam- 
matory conditions of the colon, both acute and chronic. 

Jelly-like masses or shreds of mucus, and cases where the stool con- 
sists chiefly of mucus, show that the affection is confined to the lower 
portion of the colon or that it is located in the rectum. 

Long shreds of mucus, frequently resembling false membrane, are 
often found in catarrh of the large intestine. If the shreds of mucus are 
intimately mixed with the stool, then we must look for the lesion quite high 
up, and if it comes from the small intestine it is usually stained from bile. 
If the lesion is low down the mucus is not intimately mingled with the 
stool. 

White or Light-gray Stools. — These stools usually are of a putty-like 
consistency, sometimes like dry balls on a diaper; sometimes they appear 



268 DISEASES OF THE INTESTINES. 

like ashes. Usually they are very offensive, consisting principally of fat. 
There is scarcely a trace of bile, or the latter may be absent altogether. 

Scybalous Stools. — These are hard, dry, usually round masses in which 
the intestinal lubricant is absent. These stools are usually accompanied by 
flatulence. From their stagnation in the colon the gas bacteria cause a 
chronic distention and enlargement of the abdomen. 

Dyspeptic Stool. — The first change noticed in the dyspeptic stool is the 
increase of fat. Often the stool is quite green and contains small pieces, 
of yellowish-white color, which vary in size from that of a pinhead to the 
size of an ordinary pea. Hitherto, from their color, they were supposed to 
be casein lumps. Wegscheider has taught us that they consist principally 
of fat. Baginsky has shown that large colonies of bacteria are contained 
in these lumps of fat. Frequently they are so numerous that it looks as 
though the stool were composed only of these cheesy lumps. They can be 
easily differentiated from real casein lumps by their solubility in alcohol 
and ether. 

Bacteria of the Intestines. 

There are a great many bacteria found in the intestines. These are 
present in a normal infant, as well as in an infant suffering from a gastro- 
intestinal disorder. A great many of these bacteria are, therefore, non- 
pathogenic. Miller, who carefully studied the various micro-organisms in 
the mouth, found that most of them could again be found in the intestinal 
canal. He also found that certain germs possessed diastasic properties, and 
were capable of producing lactic-acid fermentation in the milk-faeces of 
nurslings. 

Escherich found two germs, the one he called ''bacterium lactis 
aerogenes (or bacterium aceticum, Baginsky)" and the other the bacterium 
coli commune. In the meconium he found proteus vulgaris, streptococcus 
coli gracilis, and bacillus subtilis. 

Bacterium Coli Commune (Escherich). — Obtained by Emmerich (1885) 
from the blood, various organs, and the alvine discharges of cholera 
patients at Naples; by Weisser (1886) from normal and abnormal human 
fasces, from the air, and from putrefying infusions; by Escherich (1886) 
from the fa?ces of healthy children; since shown to be constantly present 
in the alvine discharges of healthy men, and probably of many of the lower 
animals. Found by Sternberg in the blood and various organs of yellow- 
fever cadavers in Havana (1888 and 1889). 

Numerous varieties have been cultivated by different bacteriologists, 
which vary in pathogenic power and to some extent in their growth in 
various culture media; but the differences described are not sufficiently 
characteristic or constant to justify us in considering them as distinct 
species. 



BACTERIA OF THE [NTESTINES. 



269 



Morphology. — Differs considerably in its morphology as obtained from 
different sources and in various culture media. The typical form is that 
o( short rods with rounded (aids, from 2 to 3 microns in length and 0.4 to 
0.6 micron broad ; but under certain circumstances the length does not 
exceed the breadth — about 0.5 micron — and it might be mistaken for a 
micrococcus; again the prevailing form in a culture is a short oval; fila- 
ments o( 5 microns or more in length are often observed in cultures, asso- 
ciated with short rods or oval cells. The bacilli are frequently united in 
pairs. The presence of spores has not been demonstrated. In unfavorable 
culture media the bacilli, in stained preparations, may present unstained 




Fiji'. 69. — Bacterium C'oli Commune. 



places, which are supposed by Escherich to be due to degenerative changes 
in the protoplasm. Under certain circumstances some of the rods in a pure 
culture have been observed by Escherich to present spherical, unstained por- 
tions at one or both extremities, which closely resemble spores, but which 
he was not able to stain by the methods usually employed for staining 
spores, and which he is inclined to regard as "involution forms." 

The bacillus stains readily with the aniline colors usually employed 
by bacteriologists, but quickly parts with its color when treated with iodine 
solution — Gram's method — or with diluted alcohol. 

Biological Characters. — "An aerobic and facultative anaerobic, non- 
liquefying bacillus. Sometimes exhibits independent movements, which 
are not very active. One rod of a pair, in a hanging-drop culture, may 
advance slowly with a to-and-fro movement, while the other follows as if 
attached to it by an invisible band (Escherich). The writer's personal 



270 DISEASES OF THE INTESTINES. 

observations lead him to believe that, as a rule, this bacillus does not exhibit 
independent movements. Does not form spores. Grows in various culture 
media at the room temperature — more rapidly in the incubating oven. 
Grows in a decidedly acid medium. 

In gelatine plates, colonies are developed in from twenty-four to 
forty-eight hours, which vary considerably in their appearance according to 
their age, and in different cultures in the same medium. The deep colonies 
are usually spherical and at first are transparent, homogeneous, and of a 
pale straw or amber color by transmitted light ; later they frequently have a 
dark-brown, opaque central portion surrounded by a more transparent pe- 
ripheral zone ; or they may be coarsely granular and opaque ; sometimes they 
have a long oval or "whetstone" form. The superficial colonies differ still 
more in appearance ; very young colonies by transmitted light often resemble 
little drops of water or fragments of broken glass; Avhen they have suffi- 
cient space for their development they quickly increase in size and may 
attain a diameter of three to four centimeters ; the central portion is thick- 
est, and is often marked by a spherical nucleus of a dark-brown color when 
the colony has started below the surface of the gelatine; the margins are 
thin and transparent, the thickness gradually increasing toward the center, 
as does also the color, which by transmitted light varies from light-straw 
color or amber to a dark brown. The outlines of superficial colonies are 
more or less irregular, and the surface may be marked by ridges, fissures, 
or concentric rings, or it may be granular. The writer has observed colonies 
resembling a rosette, or a daisy with expanded petals. Escherich speaks of 
colonies which present star-shaped figures surrounded by concentric rings. 

"In gelatine stick cultures the growth upon the surface is rather dry, 
and may be quite thin, extending over the entire surface of the gelatine, or 
it may be thicker, with irregular, leaf-like outlines and with superficial in- 
crustations or concentric annular markings. An abundant development 
occurs all along the line of puncture, which, in the deeper portion of the 
gelatine, is made up of more or less closely croAvded colonies ; these are white 
by reflected light, and of amber or light-brown color by transmitted light; 
later they may become granular and opaque. Frequently a diffused cloudy 
appearance is observed near the surface of the gelatine, and under certain 
circumstances branching, moss-like tufts develop at intervals along the 
line of growth. One or more gas bubbles may often be seen in recent stick 
cultures in gelatine. 

"Upon nutrient agar and blood-serum, in the incubating oven, an abun- 
dant, soft, shining layer of a brownish-yellow color is developed. The 
growth upon potato differs considerably, according to the age of the potato. 
According to Escherich, upon old potatoes there may be no growth, or it 
may be scanty and of a white color. In milk at 37° C, an acid reaction 
and coagulation of the casein are produced at the end of eight or ten days. 



BA( TER] A OF THE ENTESTINES. 



271 



In 1 1 10 absence of oxygen this bacillus is able to grow in solutions contain- 
ing grape Bugar (Escherich). In bouillon it grows rapidly, producing a 
milky opacity of the culture liquid. The thermal death point of Em- 
merich's bacillus, and of the colon, bacillus from faeces, was found by Weis- 
Ber to be 60° ('.. the time of exposure being ten minutes. The author has 
obtained corresponding results. Weisser found that when the bacilli from 
a bouillon culture were dried upon thin glass covers they failed to grow 
after twenty-four hours. These results give confirmation to the view that 
the bacillus under consideration does not form spores. 

"Pathogenesis. — Comparatively small amounts of a pure culture of the 
colon bacillus injected into the circulation of a guinea-pig usually cause the 
death of the animal in from one to three days, and the bacillus is found in 
considerable numbers in its blood. But, when injected subcutaneously or 
into the peritoneal cavity of rabbits or guinea-pigs, a fatal termination 
depends largely on the quantity injected; and, although the bacillus may 
be obtained in cultures from the blood and the parenchyma of the various 
organs, it is not present in large numbers, and death appears to be due to 
toxaemia rather than to septicaemia. Mice are not susceptible to infection 
by subcutaneous injection. Small quantities injected underneath the skin 
of guinea-pigs usually produce a local abscess only; larger amounts — 2 to 
5 cubic centimeters — frequently produce a fatal result, with symptoms and 
pathological appearances corresponding with those resulting from intra- 
venous injection. These are fever, developed soon after the injection, diar- 
rhoea, and symptoms of collapse appearing shortly before death. At the 
autopsy the liver and spleen appear normal, or nearly so; the kidneys are 
congested and may present scattered punetiform ecchymoses (Weisser). 
According to Escherich, the spleen is often somewhat enlarged. The small 
intestine is hyperaemic, especially in its upper portion, and the peritoneal 
layer presents a rosy color; the mucous membrane gives evidence of more 
or less intense catarrhal inflammation, and contains mucus, often slightly 
mixed with blood. In rabbits death occurs at a somewhat later date, and 
diarrhoea is a common symptom. In dogs the subcutaneous injection of a 
considerable quantity of a pure culture may give rise to an extensive local 
abscess." 

Bacterium Lactis Aerogenes. — Synonym: Bacillus lactis aerogenes 
(Escherich). 

Obtained by Escherich (1886) from the contents of the small intestine 
of children and animals fed on milk ; in smaller numbers from the faeces 
of milk-fed children, and in one instance from uncooked cows' milk. 

Morphology. — Short rods with rounded ends, from 1 to 2 microns in 
length and from 0.1 to 0.5 micron broad; short-oval and spherical forms 
are also frequently observed, and under certain circumstances longer rods 
— 3 microns — may be developed; usually united in pairs, and occasionally 



272 



DISEASES OF THE- INTESTINES. 



in chains containing several elements. In some of the larger cells Escherich 
has observed unstained spaces, but was not able to obtain any evidence that 
these represent spores. 

This bacillus stains readily with the ordinary aniline colors, but does 
net retain its color when treated by Gram's method. 

Biological Cliaracters. — An aerobic (facultative anaerobic), non- 
liquefying, non-motile bacillus. Does not form spores. Grows in various 
culture media at the room temperature — more rapidly in the incubating 
oven. Upon gelatine plates, at the end of twenty-four hours, small, white 
colonies are developed. Upon the surface these form hemispherical, soft, 




Fig. 70. — Bacterium Lactis Aerogenes. 



shining masses which, examined under the microscope, are found to be 
homogeneous and opaque, with a whitish luster by reflected light. The deep 
colonies are spherical and opaque, and attain a considerable size. In gelatine 
stick cultures the growth resembles that of Friedlander's bacillus; i.e., an 
abundant growth along the line of puncture and a rounded mass upon the 
surface, forming a "nail-shaped" growth. In old cultures the upper part of 
the gelatine is sometimes clouded, and numerous gas bubbles may form in 
the gelatine. Upon the surface of nutrient agar an abundant, soft, white 
layer is developed. Upon old potatoes, in the incubating oven, at the end 
of twenty-four hours a yellowush-white layer, several millimeters thick, is 
developed, which is of paste-like consistence and contains about the periph- 
ery a considerable number of small gas bubbles; this layer increases in 
dimensions, has an irregular outline, and larger and more numerous gas 
bubbles are developed about the periphery, some the size of a pea ; later the 



DIARRHOEA. 27 '3 

whole surface of the potato is covered with a creamy, semifluid mas- filled 
with gas bubbles. On young potatoes the development is differenl ; a rather 
luxuriant, thick, white or pale-yellow layer is formed, which is tolerably 
dry and lias. irregular margins; the surface is smooth and Bhining, and a 
few minute gas bubbles only arc formed after several days. 

Pathogenesis. — Injections o\' a considerable quantity of a pure culture 
into the circulation of rabbits and of guinea-pigs give rise to a fatal resuli 
within forty-eight hours. 

Booker, in his extended studies relating to the bacteria presenl in the 
feces of infants suffering from summer diarrhoea, has isolated seven 
varieties "which closely resemble bacterium coli commune in morphology 
and growth in agar, neutral gelatine, and potato, but by means of other 
tests a distinction can be made between them/' 

Diarrhoea. 1 

By diarrhoea is meant too frequent stools. This increased peristalsis 
is usually due to some specific cause. Infants on a liquid diet are more 
prone to loose evacuations than older children on a solid or semi-solid diet. 
Children suffering from rickets or athrepsia infantum, or any form of mal- 
nutrition, are more prone to the development of diarrhoea. The cause of 
the bulk of the cases of diarrhoea seen by me during the last fifteen years, 
in one of the largest dispensaries of Xew York City, was bottle-feeding. 
Out of 1000 cases of diarrhoea 900 were bottle-fed and lived amid poor 
hygienic surroundings. In 90 cases the children were breast-fed. but there 
was a disturbance during lactation. This disturbance was pregnancy. 
menstruation, tuberculosis, or syphilis in the mother, or prolonged nursing 
with deficient fats and proteids. 

In 10 cases there was no assignable cause excepting the subnormal con- 
dition of the body due to an excess of midsummer heat. 

Contaminated Milk. — Impurities such as bacteria, filth, and chemical 
products due to fermentation can easily cause diarrhoea. In my article on 
"Bacteria in the Intestine," I describe the two most frequent varieties of 
bacteria which are normally found in the intestine. They are the bac- 
terium coli and the bacterium lactis. These bacteria frequently assume a 
virulent form under certain conditions. They very often cause diarrhoea. 
Other bacteria, such as the streptococci, can be introduced in cows" milk. 
A diseased udder in the cow will frequently secrete pus in addition to milk. 
Such milk must necessarily cause trouble when introduced into the in- 
fantile stomach or bowels. 

Improper Diet for Older Children. — We frequently see people who' 
think it wise to give their children, regardless of their age, a bit of any- 

1 See also chapter on "Acute Milk Infection." 

18 




274 DISEASES OF THE INTESTINES. 

thing from the table. Eaw fruits and raw vegetables, cabbage, and pickles 
are given regardless of the consequences. In studying the dietetic sins com- 
mitted by the parents of children in two dispensaries located in different 
sections of New York City, I found the following conditions : — 

One hundred children between the second and sixth years of age 
living in tenements apparently healthy; 80 received a taste of beer or a 
drop of whisky diluted with water every day. In some families the children 
received as much as a wineglassful and more of beer with each meal. Such 
imprudence is frequently a distinct factor in the causation of diarrhoea. 

Nervous Diarrhoea. — The influence of fright or excitement is the best 
example of diarrhoea due to nervous influence that can be given. When 
caused by a nervous influence the faeces contain mucus, and there is usually 
an explosive stool. It is a form of exaggerated peristalsis. Chilling the 
surface of the body frequently provokes diarrhoea, 

Diarrhoea as a Symptom of Disease. — Nature's method of eliminating 
poison is frequently seen when a diarrhoea commences in the course of an 
acute infectious disease. Toxic products can best be eliminated by the 
emunctories, and the intestines are one of the most valuable agents for 
eliminating poison from the body. The diarrhoea of typhoid fever, sum- 
mer complaint, dysentery, and ileo-colitis have been described in their 
respective chapters. 

Treatment. — Seek the cause and if possible remove the same. If a 
dietetic error has caused the diarrhoea, then a good dose of castor-oil should 
be given. In all events a good cleansing should begin the treatment. Mist, 
rhei et soda in teaspoonful doses can be given several times to cleanse the 
gastro-intestinal tract. Several hours after the laxative has been given the 
rectum and colon should be flushed with hot water containing a teaspoonful 
of salt to each pint. The temperature of the saline solution should be about 
110° F. 

Bismuth in 3 to 10-grain doses, repeated every two hours, is our best 
remedy. 

B Mist, creta 2 ounces, 

one teaspoonful every two hours, is also valuable. 

Diet. — Stop all milk. Give whey and rice water thickened with potato 
flour or wheat flour. Give the white of egg several times a day ; also cocoa 
and water. 

For Thirst. — Give 5 to 10 drops of diluted hydrochloric acid in a tum- 
blerful of boiled water (sterilized). This can be given ad libitum. 

Diluted phosphoric acid, 20 drops to a tumblerful of sweetened water, 
is a pleasant drink during fever. It is also stimulating. 

The following charts were kindly furnished to me by Dr. William H. 
Guilfoy, Chief of the Bureau of Statistics, Health Department, City of 
Xew York : — 



DIAKKIKKA. 



27-") 




276 



DISEASES OF THE INTESTINES. 



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DISEASES OF THE INTESTINES. 



Dysentery (Ileo-colitis). 

The lower portion of the intestine is frequently the seat of an infection 
by pathogenic bacteria. 

Pathology. — As this condition frequently follows severe milk infection, 
the pathogenic lesions are necessarily the same, although in a more ag- 
gravated form. In addition to the hypersemia of the mucous membrane 
there may be a small haemorrhage in the mucosa or submucosa. The mucous 
membrane is very deeply pigmented, frequently being of a purplish line. 





Fig. 72. — Bacillary Diphtheria of the Colon or Diphtheritic Colitis, a, 
Necrotic tissue containing bacilli. I, Gland with necrotic epithelium, d, 
Connective tissue, e, Degenerated and exfoliated epithelial cells, f, Bacilli 
in the lumen of the gland, g, Bacilliary deposit beneath the epithelium. 
h, Nests of bacilli in the connective tissue. X 300. ( Ziegler. ) 

The solitary lymph follicles along the colon are swollen. The discharge of 
mucus is tinged with blood, and not infrequently the amoeba coli described 
by Losch, or known as the amoeba dysenteries, described by Councilman and 
Lafleur, can be found. "It is a unicellular, protoplasmic, motile organism 
from 10 to 20 micro-millimeters in diameter, and consists of a clear outer 
zone (ectosarc) and a granular inner zone (endosarc), containing a nucleus 
and one or more vacuoles." Multiple abscesses are frequently found. "The 
ulcer first begins as a small papule, the upper part of which sloughs off, 
leaving a grayish-yellow ulcerating surface." 

Amoebic Dysentery. 1 — Five cases are reported. The diagnosis was based upon 
the findng of motile amoebae containing red blood-corpuscles. The cases were 
moderate in intensity. The age of the children was 2 to 5 years. Four were 
boys. They came under observation at the dispensary. 

1 Amberg: Bulletin Johns Hopkins Hospital, December, 1901. 



DYSENTERY. 



27 ( .) 



Little fever was present. The stools varied in frequency from four to twenty 
four. Only one complained of much pain. In two cases prolapsus recti occurred. 
No abscess of liver was found. The reaction of the fseces was mostly alkaline. 
They were offensive, liquid or solid, and accompanied by bloody mucus. The 
amoeba may be found only on repeated examination. If in the passages of ;t child 
Charcot-Leyden crystals are found, amoebic dysentery should be considered. The 
blood picture varied greatly. A leucocytosis (13,800 to 27,000) existed in every 
ease when first examined. 




Fig. 73. — Croupous Enteritis, Diphtheritic Colitis, two-thirds 
natural size. (Langerhans.) 



Diphtheritic dysentery, sometimes known as the croupous variety, is 
a catarrhal form of this same condition previously described, in which the 
infection can be traced to an invasion of the Klebs-Loeffler bacillus. The 
ulcerations are covered with a pseudo-membrane, and the pathogenic con- 
ditions are as previously described. 

Bacteriology. 1 — There are two groups of bacilli which are responsible 
for the development of various types of epidemic dysentery : — 

1. The true Shiga group. 

2. Group of mannite fermenters. 

The latter group is divided into two types: — 

(a) Fermenting mannite alone in peptone solution. 

(b) Fermenting maltose and saccharose. 



The Journal of Medical Research, vol. xi, No. 2, May, 1904. 



280 



DISEASES OF THE INTESTINES. 



Park, Collins, and Goodwin believe that it is more practical to divide 
the bacilli having the characteristics of the bacillus isolated by Shiga, and 
call them dysentery bacilli. The other two groups resemble more closely 
the colon gioup. in that they produce indol and have a greater range of 
activity in fermenting carbohydrates; hence, they are called para-dysentery. 
Park believes that the prefix para will distinguish that form of dysentery 
occasionally seen in epidemics of the milder type. 

When a case of dysentery is found in a family it should immediately 
be isolated. The infection can no doubt be disseminated through the alvine 
discharges. 

According to a statement of Dr. W. H. Park to the author, the Shiga 
bacillus is present in all the stools found in Xew York City which contain 
blood and mucus. 

The following case attended by me in the family of Dr. J. Morgen- 
stern will serve to illustrate the character of dysentery as seen in Xew 
York City :— 

Case I. — (a) A child about 4 years old was taken sick after an imprudent 
diet, with bloody stools and general symptoms of dysentery. There were the usual 
gastric disturbances. After a careful diet and intestinal astringents, such as bis- 
muth and chalk mixture, the child recovered. 

(&) Several days later a female infant in the same family, 13 months old, was 
suddenly attacked with diarrhoea. The infant had from ten to thirty evacuations a 



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Fig. 74. — Dysentery. Baby M., Thirteen Months Old. Seen Fourth Day 
Illness. Serum Injected. (Original.) 



of 



DYSENTERY. 281 

day. When 1 firsl -aw the child the stools contained blood for the pasl four days. 
The child had been perfectly well during the summer. Was breast-fed until 
September. Since weaning there has been more or less gastro-intestina] trouble. 

Treatment. — The usual astringents, such as bismuth and chalk mixture, were 

tried with little or no success. High colon flushings of starch water and a weak 
solution of nitrate of silver were tried with no benefit whatsoever. The bloody 
stools continued and the doctor reported that there was more tenesmus, also a pro- 
lapse of the rectum. 1 discontinued the colon flushings and injected 20 cubic centi- 
meters of anti-dysenteric serum. l Decided improvement was noticed after the 
serum injection. Two days later the stools decreased in number and there was no 
more evidence of blood. 

Four days after the injection the bowels did not move for twenty-four hours. 
The appetite improved and the child convalesced. I ordered some iron internally as 
an astringent and restorative. A careful diet was ordered of cocoa with diluted milk, 
rice and gelatine pudding. 

Case II. — A child of Dr. M., eighteen months old, was seen by me in August 
of 1003. The family was at Long Branch. The following history was given. There 
was vomiting and diarrhoea, great prostration, loss of appetite, and extreme thirst. 
The stools contained blood and mucus. There was severe tenesmus. The child had 
stools as frequently as every five or ten minutes. The pulse was very small and 
thready. The heart sounds were feeble. The temperature in rectum, 101° F. The 
diagnosis of dysentery was made. 

Treatment. — The rectum and colon were cleansed with a pint of starch water, 
to which a half-teaspoonful of alum was added. Two teaspoonfuls of castor-oil were 
given by mouth. 

Milk was stopped and whey was ordered. Twelve hours later the child was 
again seen, and as there was no improvement suppositories containing the following 
were ordered: — 

I£ Argent, nitrat 1 grain 

Oleoresin terebinthin 10 grains 

Cocoa butter 2 drachms 

M. and divide into suppositories No. x. 

Sig. : One suppository every three hours. 

Twelve hours after the above treatment was begun, the diarrhoea still persisted, 
and the exhaustion and heart weakness were very alarming. I injected 10 cubic 
centimeters of anti-dysenteric serum (Harris). This injection was given into the 
connective tissue of the abdomen. The child improved rapidly, and I believe the 
serum aided the recovery. Elixir of calisaya and wine were given, in addition to 
coffee, as stimulants during illness. 



Symptoms. — The attack is usually ushered in with diarrhoea. There 
is also considerable straining with each stool. At first the stools contain 
particles of faeces, and as the disease progresses they become more liquid 
and contain mucus and blood. Some authors describe the stool as con- 
taining shreds that resemble the washings of raw meat. The face shows 



1 For the serum I am indebted to Dr. William H. Park, of the Xew York 
Health Department. 



282 DISEASES OF THE INTESTINES. 

a very anxious expression. There is extreme pallor. The child appears 
prostrated. The pulse is accelerated and very feeble. The abdomen is 
distended, especially over the colon. Vomiting is a rare symptom. Unless 
treatment is rapidly instituted the child will fail in strength and may die. 
Such children usually sleep with the eyes half open and show evidences 
of collapse. The rectum may protrude, especially when there is a distinct 
relaxation of these parts. Cold, clammy perspiration is usually found, 
especially on the head. The extremities are cold. Convulsions appear in 
the severer forms of dysentery. In the diphtheritic variety the temperature 
and pulse resemble a case of true diphtheria. The stool, in addition to 
mucus and blood, may have particles of pseudo-membrane. Toxaemia can 
usually be seen by its effect on the heart and pulse. The urine may contain 
albumin. Where the toxaemia progresses, convulsions may set in and death 
result from cardiac paralysis. 

Diagnosis. — The bloody mucus and watery stools seen in this con- 
dition, associated with tenesmus, will usually aid in eliminating acute 
milk infection. In gastro-enteritis and entero-colitis there is usually a 
greenish spinach-like stool, or a brown muddy stool having a very foetid 
odor. The stools in dysentery are smaller in quantity. Both the diph- 
theritic and the amoebic forms of dysentery are rare in children. 

Prognosis. — If this disease is epidemic, or if it occurs in children 
having bad sanitary surroundings, then the prognosis is bad. The dura- 
tion of an acute attack usually lasts about five or six days. The prognosis 
is good when the diarrhoea and blood gradually disappear. The main 
point to remember is that the heart must be sustained by proper nutrition, 
and we should try to counteract the toxaemia by proper stimulation. 

Treatment. — The same hygienic measures described in the chapter on 
"Acute Milk Infection" apply equally as well here. Impress the mother 
or nurse that unless she carries out the directions minutely, the child has 
little chance of recovery. 

Dietetic Treatment. — The dietetic management will consist in leaving 
out milk. Whey, barley water, rice water, or toast water may be given. 
Mutton broth thickened with rice may be given to an older child. Whisky 
and water should be given from the beginning. It is not too much to give 
2 to 4 ounces of whisky per day. The physician should order the amount 
of whisky by telling the mother or nurse to give 1 / 2 drachm or more well 
diluted with barley or rice water, every half-hour. 

Coffee is a valuable cardiac stimulant. Champagne may also be given. 

Local Treatment. — The physician will be most successful who places' 
his patient in bed, regulates the diet, cleanses the intestinal tract, and 
relieves the tenesmus by local treatment. The heart should be supported. 
The strength must be sustained with nutrition and the flushing of the bowel 
should be performed as soon as possible after a stool is evacuated. 



( ONSTIPATION. 

Warm chamomile tea should be used to cleanse the colon and rectum. 
This should be injected at a temperature of 110 c to 115* I\. with the aid 

- ill rubber catheter. This can be followed by an injeci 

ounce of sterile water containing 2 grains of nitrate of silver. Very 

injections, such as 

R Raw starch It aspoonful 

Chamomile tea 1 quart 

Laudanum 10 drops 

injected at a temperature of 100 € F.. will soothe the rectum and frequently 

relieve tenesmus. I have successfully treated dysentery cases with the 

following : — 

R Argentum nitrate grains 

Cocoa butter q. s. 

M. Form into twelve suppositoi : 

R Oleo resin terebinthina? 12 grains 

Extract of belladonna grains 

Extract of opii aquosa 1 grain 

a butter q. s. 

M. Form into twelve suppositories. 

Sig. : Insert alternately q. 3 hours. 1 

Sulpho-carbolate of soda, in doses of 5 to 10 grains, can be used 
several times a day. Bismuth combined with Dover's powder is frequently 
valuable. An ice-bag placed on the abdomen in the region of the colon will 
sometimes do good. Very cool injections of table salt and water are some- 
times of value when hot injections are not well borne. 

m Treatment. — The value of serum treatment can best be judged 
by reading the clinical cases in this article. 

: xstipatiox axd Chronic Coxstipatiox. 

The bowels of an infant during the nursing period should have one, 
two. or three evacuations daily. Some children will be quite normal with 
one evacuation daily. Older children who partake of solid food suffer 
more frequently with constipation. There are decided peculiarities noted 
in children with reference to the movements of the bowels. One child 
will enjoy good health, have a good appetite, and will gain in weight with 
three or four movements of the bowels daily. Another child in equally 
good health will have but one movement daily. These differences or 
peculiarities must be taken into consideration before definitely maintain- 
ing that our patient is really constipated. If a child has no movement 
in twenty-four hours. I usually suspect constipation. When this condition 
continues for a period of weeks or months, then we may say chronic con- 
stipation exists. 

- As the nitrate of silver would oxidize the organic matter contained in the 
second formula, the suppositories must be given at intervals of 3 hours. 



284 DISEASES OF THE INTESTINES. 

Causes. — 1. Dietetic. 2. Anatomical. S. Systemic. 

Dietetic Causes. — This condition is most frequently met with in bottle- 
fed infants. There are several causes which generally contribute to stag- 
nant faeces: — 

First. — Cows' milk with its thick casein is much more difficult to 
digest. An excess of casein in the food frequently induces constipation. 
In some infants the moment we increase to more than 1 per cent, of 
casein, constipation will result. A deficiency in the amount of sugar will 
frequently cause constipation. This applies to breast-fed infants as well 
as to bottle-fed infants. 

Second. — The application of heat to milk, especially when sterilization 
is continued, results in constipation. 

Third. — When milk contains a deficiency of fat the excess of casein 
will stagnate. 

Fourth. — The infant is frequently dyspeptic or rachitic, and in this 
latter condition the peptic and intestinal glands do not perform their nor- 
mal functions; this absence of intestinal glandular secretions is one of the 
main factors resulting in constipation. 

Fifth. — When water is not given to an infant it frequently sutlers 
with constipation. 

Anatomical Changes. — Jacobi says: "The embryonic intestine is 
formed in separate divisions. There is no ascending colon up to the fourth 
or fifth month of foetal life. It is very short in the mature new-born. 
Despite this, the large intestine of the mature foetus is longer in propor- 
tion than that of the adult, It is three times as long as the body of the 
foetus, while it is only twice as long in the adult. There is the same dis- 
proportion with regard to the length o" the small intestine. The small 
intestine of the foetus in the ninth month is twelve times as long as its 
body. The small intestine of the adult is only eight times as long as the 
body." 

The colon ascendens being very short, the surplus of length, partic- 
ularly as the transverse colon also is not long, belongs to the descending 
colon, and especially to the sigmoid flexure. Drandt found it between 8 
and 24 centimeters in length, averaging from 14 to 20 centimeters. Jacobi 
saw a case in which it was 30 centimeters long. 

As the pelvis is very narrow, the great length of the lower part of the 
large intestine is the cause of multiple flexures, instead of the single sig- 
moid flexure of the adult. Thus it is that, now and then, two or even 
three flexures are found, and to such an extent that one of them may be 
found to extend as far as the right side of the pelvis. Cruveilhier and 
Sappey speak of this position of the lower part of the intestine in the 
right side of the pelvis as an anomaly. Huguier finds it on the right side 
of the body in the majority of cases. Others only occasionally, although 



t ONSTIPATION. 



285 



they admit the great Length of the sigmoid flexure. In common with 
Huguier, who even proposes to operate for artificial anus in the right Bide, 
Jacobi found one of the flexures on the right side many times. 

The great length of the Large intestine and the multiplicity of its 
flexures are of great functional importance. At all events, they retard the 
movement of the intestinal contents, facilitate the absorption of fluids, and 
thus the faeces are rendered solid. When this length is developed to an 
unusual extent, constipation is the natural result. In the American Jour- 
nal of Obstetrics, August, 1869, Jacobi described two cases in which the 
descending colon was so long that the diagnosis of imperforate rectum was 
made. In one of them the operation for artificial anus was performed. 1 
"Such cases and such errors are certainly very rare; still there are those in 
which normal anatomical conditions will lead to incidents of great patho- 
logical importance." 

Records of post-mortem observations made by Dr. T. C. Martin 2 prove 
that the muscular development of the adult rectum and lower sigmoid is 
plainly apparent, and. that a deficient muscularity is observable in the in- 
fant specimens. In the infant gut the intrinsic power of peristalsis is not 
present in that degree necessary to it as a competent expulsory factor. 

The meso-peritoneum of these parts in the adult is, relatively, very 
considerably shorter than that in the infant. The adult gut is slightly 
tortuous ; that of the infant is much angulated. Mobility and angulation 
of the infant gut conspire to obstruct the passage of formed faeces. 

The rectal valve appears to bear the same proportion to the gut in both 
adult and infant, but when the difference in nruseular development in the 
two is noticed the disproportionate great resistance of the valve in the 
infant rectum becomes an obvious fact. 

Systemic Causes. — Incomplete peristalsis, such as exists in the rachitic 
debility of the muscular layer, in the muscular debility dependent upon 
sedentary habits and peritonitis, intestinal atrophy, and hydrocephalus. 

Mechanical Obstruction. — Cystic tumors in the intestine. There is, 
further, intussusception and twisting of the intestine, incarcerated hernia, 
even umbilical hernia, hardened fseces, and imperforations. 

In -all these cases the diagnosis should not be made without manual 
examination. In most of the cases the abdomen is inflated, though it be 
painless. The fa?ees come away in small, hard lumps or in large masses. 
The liver and spleen are displaced. The liver may be so turned that a part 
of its posterior surface comes forward. The abdominal veins are enlarged 



1 For a detailed description see "Concetti, Archiv fur Kinderheilkunde.** vol. 
xxvii, 1S99. 

2 "A Study of the Difficulties of Defecation in Infants." by Dr. T. C. Martin, 
read at the forty-eighth annual meeting of the American Medical Association, June 
4, 1897. 



_v 




DISEASES >* THE IXTESI 




F:_: " r — Ascending Position. 



Fi* ": — A~:-rZ ".::-._ I -::: :n 




■"■' m 




Kg "" — Transverse _ sition. 



_ ._ 75 — _: :.zi r. — r :s:::::l 




Kg " r —Descending Position. 




Kg ; 0. — Descending Position. 



IUiistrations of the Tarions types of abnormality of the sigmoid 
flexure, which are the source of habitual constipation in Infants. A::^r 



I ONSTIPATION. 

to such an extent that they form circle? around the umbilicus, similar to 

what is seen in hepatic cirrhosis. These children lose their a: . some- 

times vomit, and the irritation produced by the hardened masses in the 

nal canal may be such as to finally result in diarrhoea, which, how- 

. is not always sufficient to empty the tract. 

There is, besides, an apparent constipation, which should not be mis- 
taken for any of the above varieties. Now and then a child will appear to 
be constipated, have a movement every two or three days, and at the same 
time the amount of faeces discharged is very small. This apparent con- 
stipation is seen in very young infants rather than in those of more ad- 
vanced age. Such children are emaciated, sometimes atrophic. They ap- 
pear to be constipated because of lack of food, and not infrequently this 
apparent constipation is relieved by a sufficient amount of nourishment. 

As there is frequently a large excess of acid in the intestine, magi: - 
with or without rhubarb, will frequently relieve the acidity and cause a 
movement of the bowels. 

In the chapter on "Cream*' I have already spoken of the deficiency of 
fat. which is one of the most frequent causes of constipation. Hence, in 
an infant nursing at the breast it is wise to give the child a teaspoonful 
of raw cream immediately before taking the breast to correct the consti- 
pation. Cream consists of so much fat that in this manner we add fat 
directly to our food. This is the secret of success attained by some authors 
when they advise giving codliver-oil. butter, or olive-oil to very young 
children. Each one desires to remedy the deficiency of fat in his own par- 
ticular manner. 




Rubber Bulb Svrincre. 



Symptoms. — In older children, headaches, restlessness, and occasion- 
ally abdominal pains are complained of. / have frequently seen high tem- 
perature caused by constipation, which temperature disappeared soon after 
the evacuation. Restlessness at night, continued crying in young infants, 
with the legs drawn up on the abdomen, and fretfulness indicate colicky 
pains, frequently the result of constipation. 

Treatment. — Immediate Belief (Removal of >>ybala) : Hardened 
round balls or fragments of fa?ces will frequently be caused when the stool 
remains very long in the colon, or when the sigmoid flexure has an unusual 
length: in such instances the injection of either 1 - 2 pint of lukewarm 
sweet oil or glycerine will soften these "seybala and aid in their expulsion. 



288 



DISEASES OF THE INTESTINES. 



At times these balls will be as hard as marbles, and may require the aid 

of a small scoop (the handle of a teaspoon will do) to aid in their removal. 

Enema. — A rule that I have always followed, and one that I lay 

stress upon, is never to allow a child to retire at night without having had 




Fig. 82. — Irrigator, with Tube Attached and Hard Rubber Points. 

a movement of the bowels during the clay. The reason for this is plain : 
not only will the accumulated faeces and gas cause flatulence, colic, and 
uneasiness, but this constant distention of the bowels will dilate the intes- 
tines to such a degree that frequently a permanent pendulous belly remains. 
My plan is to order an injection of a half -tumbler of ordinary glyc- 
erine mixed with a pint of warm water — temperature, 100° F. — and to 




Fig. 83. — Soft Rubber Rectal Tube for Irrigating the Colon. 

allow this quantity to flow into the rectum by using a fountain-syringe the 
end of which has the smallest infants' rectal nozzle. In this manner we 
have a rapid emptying of the rectum and colon, and can be assured of tem- 
porary and, possibly, permanent relief. It is not absolutely vital to use 
glycerine and water, for a similar result can be obtained if we make soap- 
water by rubbing up Castile or glycerine soap in a pint of warm water. 



?TIPATIOX. 



2- 



\§ma, — In obstinate cases it is well to slip a s - 
rubber rectal tube over the nozzle, and, having anointed the rubber tube 
with vaseline or glycerine, the same can be pushed slowly into the rectum, 
then allow about half a pint of water to flow into the rectum, which will 
distend it gradually, and, by simply pushing the tube farther into the colon, 
we can allow the balance of 1 pint or more to flow directly into the colon. 
The continued use (daily) of these enemas is not fraught with danger; 
on the contrary, these rectal injections can be used for months. Ir. 
hands, if the mother or nurse is intelligent, there should be not only no 
injury, but positive good, from their continued use. 

. / Cold Waler. — The injection of cold water through a soft flexible 
catheter or with the aid of a rectal tube acts as an excellent tonic. This 
injection repeated once a day should be practiced for a long time. If we 
can teach the child to retain the cold water so much the better. The stim- 
ulus of the cold water is especially valuable when constipation is due to 
chronic colitis associated with catarrh. 

:;~.\'5. — Azi-izlz :h:~ no?: cr— ::"j isei ire smT-isitiries 
of the glycerine and gluten type. 1 Most suppositories in the market are 
entirely too large, and frequently must be cut into halves and quarters. 
The suppository made by John A. WyeQi & Co. has served the author ?e rj 
welL It should be distinctly understood that a suppository is to be used 
in the evening for the same relief as we desire from the injection or enema 
prfTiz-is'.T 2iri:::ie:. NYlner zl~ r: t::::; n:: tie in'fZTi::: slili be 
used with the idea of curing a constipation. 

Hygienic Treatment. — ^~t insist m proper veatOatka of a 

child's sleeping-room at night, and it is, therefore, advised that the window 
be left open a few inches. This is not fraught with danger; on the con- 
trary, it is healthful and beneficial to allow children to play in the open 
air all day, and naturally to shut them up in poorly ventilated apartments 
at night is simply inviting both throat and lung trouble. In addition to 
proper ventilation,. bathing in cool water or lukewarm water, followed by 
an abdominal spray or a douche directed against the stomach and bowels, 
will be found advantageous in the correction of this ailment. Following the 
bath, friction with a good, coarse, Tnrkish towel will be found useful. 
iTfiririii-e lbs i. ; ;ti: ::: :. /. n ::.._ ~ : " : 

for a few moment- . e~riv morning, and then to have the child properly 
rubbed until the skin is reddened with a Tnrkish toweL, followed by mi - 
with oil or vaseline. 

Mechanical Treatment. — J at massage is for a yon: _ 

fant exercise is for an older child. Thus, it is apparent that atonic con- 
ditions can best be relieved by combining the dietetic and medicinal treat- 



ilnten suppositories axe made by the Health rood Company, of - 



Qfcr. 



::- 



290 DISEASES OF THE INTESTINES. 

ment with out-of-door exercise. Children should be permitted to romp 
about and walk and play out of doors, but not to a point approaching 
fatigue. Older children will find bicycle exercise or horseback riding de- 
cidedly beneficial. It is important, however, to regulate the amount of 
such exercise, and thus it is the physician's duty to tell the mother or nurse 
just how long a child should be permitted to exercise. It would seem that 
one-half hour twice a day is ample to arrive at beneficial results. Over- 
indulgence in such sports will frequently result in rupture and produce 
heart strain. In cardiac lesions, in asthmatic conditions, if children surfer 
with whooping-cough, and in tuberculous conditions, such exercises must 
not be allowed. 

Massage. — Continued kneading of the abdomen with the aid of vase- 
line or oil will be found serviceable, and, if properly done, will provoke an 
action of the bowel. Thus it is that rubbing the abdomen with castor-oil 
has frequently been recommended in the treatment of constipation; the 
effect supposed to be due to the castor-oil is, in reality, due to the massage, 
and to nothing else. When vibratory massage is used, it should be con- 
tinued from five to ten minutes every day for one month. This will cer- 
tainly aid and stimulate peristalsis, and ultimately tone the muscles and 
cure the constipation. 

Method of Performing Massage. — The hands are genth placed on the 
right side of the abdomen at about the ileo-caecal region. Gentle pressure 
should be made; otherwise, the abdominal muscles will be tense. Com- 
mence each stroke of the massage with gentle pressure and utilize each 
inspiration for firmer and firmer pressure. The same method of palpation 
which is employed for the diagnosis of a tumor in the deep tissues should 
be employed. After firm pressure has been made, we can then gradually 
massage by a rotary movement, first the ascending colon, continue over 
the transverse colon, and finally over the descending colon and rectum. 
Hardened scybala can frequently be felt in the region of the caecum and can 
be propelled by this mechanical treatment through the various portions of 
the colon to the rectum. 

Length of Time Required for Each Massage. — From five to ten min- 
utes every morning and evening can be continued for several weeks. If 
improvement is noted, then less frequent treatment is required. To be 
successful, several months of treatment may be necessary in obstinate cases. 
We must persist in stimulating the peristaltic waves regularly and not be 
disappointed if immediate results are not secured. My plan has always 
been to inform the parents that I do not expect any success in a chronic 
constipation which has persisted for months or years, until six months or 
more have passed. 

Electricity. — This is very valuable to stimulate peristalsis. The 
faradic, galvanic, or static current can be used. For the general practi- 



« I fNSTIPATH >N. 291 

tioner the use of the galvanic current, five to ten cells, is sufficient. I 
_ tive pole (cathode) should be applied in the rectum, and the positive 
. which produces peristaltic waves, Bhould be applied over the ascend- 
s ending, and transverse colon. Local contractions result from the 
_ tive pole. A gentle faradic current applied over the spine and the 
abdomen will answer if used for Beveral minutes in the absence of the 
galvanic current. Galvanic electricity should be used every day ; fre- 
quently months are required to insure a cure, in conjunction with the 
medicinal and dietetic treatment. 

Dietetic Treatment. — We have previously mentioned the value of 
cream and the addition of water for the treatment of constipation. In 
bottle babies it is well to remember that oatmeal water and sago water should 
be used when constipation exists. Under no condition should barley or rice 
be given, as the latter will simply increase the constipation. Older children 
should be given fruit, baked apples, tamarinds, apricots, peaches, prunes, 
grapes, and oranges. Buttermilk will be found serviceable, as well as 
kumyss, for the relief of constipation. Sugar ( cane-sugar ) will be found 
quite serviceable, when added to water, for the relief of constipation in 
nursing or bottle-fed babies. Thus, a good plan is to give a small piece 
of loaf sugar dissolved in water immediately before nursing, and to sub- 
stitute and use cane-sugar instead of milk-sugar for bottle-fed babies. 

Having regulated the diet and excluded fresb bread, cakes, pies, 
pastries, macaroni, and other floury foods, we should insist, in children 
over 2 years of age. on eating all green vegetables with the exception of 
cabbage, beans, turnips, potatoes, and corn. Thus, celery, spinach, green 
peas, asparagus, and cauliflower are recommended. 

A Drink of Water. — From infancy, when the child is but a few davs 
old., we should make it a rule to give it a drink of water ; a very small 
infant during its first week can be given two or three teaspoonfuls of 
boiled water during the day. A safe plan is to give this drink of water 
when it is not time for feeding, and if the child appears restless. 

Drug Treatment. — A great many drugs are indicated and contra- 
indicated in the treatment of constipation. The intelligent practitioner 
does not desire merely one movement of the bowels, brought about by 
drugs, but seeks rather to use such therapeutic measures as will give a per- 
manent cure. My choice of drugs is the following: — 

R Ext. cascara sagrada tl 1 ounce 

Glycerine 1 ounce 

M. Twenty drops of the above mixture in a teaspoonfa] of water three 
time- a day. for children about three months old. At the age of fix months, double 
the dose, or 40 drops three times a day. At the age of 1 year a teaspoonfa] three 
times a day. 



292 DISEASES OF THE INTESTINES. 

Another valuable preparation is malt extract with cascara, in tea- 
spoonful closes, once or twice a day. 

My plan is to give the first dose in the morning before the feeding, 
and note the result. If the bowels move by noon-time then I discontinue 
the dose at noon, and give a second dose in the evening. If, however, there 
is no effect by noon-time, then I continue my second dose, and follow with 
my third dose in the evening. Thus, it will be apparent that, if one dose 
answers for the day, then we should discontinue the medicine for that da}', 
but commence again on the following day, and keep up this form of drug 
treatment until it is apparent that the bowels are not as sluggish in their 
action as before. Another drug which has been one of my stand-bys for 
many years is nux vomica. I give 1 drop of the tincture of nux vomica 
in a teaspoonful of sweetened water three times a day, for an infant up 
to 1 } T ear of age. Children of 2 years I give 2 drops three times a day. 
From 3 to 6 years, 3 drops three times a day. Six to 10 years, 4 drops 
three times a day. Ten to 15 years of age, 5 drops three times a day. Nux 
vomica is always to be administered on an empty stomach ; in other words, 
before feeding. Another valuable drug is rhubarb in the form of the 
aromatic syrup of rhubarb. From ^ to 1 teaspoonful once or twice a day, 
repeated every two days, will frequently afford relief. 

Powdered rhubarb and magnesia, given in teaspoonful doses to very 
young children, is one of the best laxatives and antifermentatives that we 
possess. It is especially indicated for the relief of colic. 

Citrate of magnesia, given in wineglassful doses to children over 1 
year of age once or twice a day, can also be recommended. 

In atonic conditions of the bowels depending on general weakness, 
strychnine, given in V200 or Vioo-g 1 ^ 11 doses twice a day, will be found 
useful. This may or may not be combined with iron. 

The infusion of senna leaves is made by boiling a heaping teaspoonful 
of ordinary senna in a teacupful of boiling water for fifteen minutes, strain- 
ing, and when cool adding 1 tablespoonful of glycerine to 5 tablespoonf uls of 
this infusion of senna. This quantity to be administered in three doses at 
intervals of four or five hours. In some instances the addition of syrup of 
manna will be found advantageous in sweetening the infusion of senna. 

Phosphate of soda, in doses of 5 to 15 grains, given in milk with the 
food, is a mild and sure laxative. A pleasant preparation sold in the shops 
is known as milk of magnesia. It is a good antacid and laxative when 
given in doses of % to 1 teaspoonful. 

Certain drugs should not be given. Of these, castor-oil may serve as a 
type. The constipating effect following the use of castor-oil is so well 
known that this drug is indicated when we wish to cleanse the stomach and 
bowels and remove stagnant food, as, for example : in fermentative dys- 
pepsia accompanied by diarrhoea. Thus, we not only have an effective 



[NTESTINAL COLIC 



293 



movement, but a constipating effect following the same. The use of drastic 
cathartics — Buch as Bcammony, elaterin, or podophyllin — should not bo 

thought of in the treatment of infants and children. Very rarely do I 

use aloes, owing to its offensive taste. It is understood that calomel is only 
to be given when we wish to cleanse and produce an antiseptic effect in 
the intestine; for the treatment of constipation per sc, calomel is entirely 
out of place. 

Intestinal Colic (Intestinal Neuralgia: Enteralgia). 

Intestinal colic consists of pain which is paroxysmal in character, 
located in the bowel, and without evidence of inflammation. 

Symptoms. — Colic is one of the most frequent causes of crying in 
children. They not only cry loudly, but will suddenly shriek, and when 
put to sleep will awaken with a sudden start, and cry loudly. The legs are 
usually flexed or they will move their legs back and forth, or up and down. 
They will seem to bend the body on itself. These attacks are usually asso- 
ciated with constipation; hence, it is a good plan, when the child is rest- 
less and utters a painful cry, to see if the bowels have moved. It is well 
known that this colic may be as well associated with diarrhoea. The origin 
of all colic is certainly the stomach. When dyspeptic conditions, arising 
from undigested particles of food in the stomach, exist, then fermentation, 
resulting in gas formation, is the result. Colic is frequently, but incorrectly 
known by the terms of "meteorismus" or "tympanites," but in the latter 
conditions the abdomen is greatly distended, and there is a permanent 
enlargement of it. Borborygmus (rumbling sounds) can usually be made 
out, if the ear is applied to the abdomen. The vast majority of cases of 
colic have their seat in the intestine, and can be relieved very quickly. 

Causes. — "Worms (ascarides) have been known to cause colic. When 
there is a general loss of tone on the part of the muscular layers in the walls 
of the intestine, colic will frequently result. Jaeobi believes that colic can 
be caused by chronic peritonitis resulting in adhesions or local changes in 
the walls of the intestine that will produce local contractions or dilatations. 

Excess of Sugar. — When colic is caused by an excess of sugar, there 
will be considerable eructations of gas, and, frequently, small quantities of 
food will be regurgitated. 

The stools, when an excess of sugar is given, are thin and greenish. 
smell very acid, and usually produces a reddened excoriation of the buttocks 
around the anus. 

When children show a tendency to the development of gas and have 
constant recurring colic, my plan is to discontinue the use of sugar until 
such time as this fermentation is absent, To sweeten the food I use small, 
saccharine tablets, 1 grain being ample to sweeten 1 pint of food. When 
there is a tendency to constipation, it is possible not only to sweeten the 



294 DISEASES OF THE INTESTINES. 

food, but also to modify this constipation by adding 1 teaspoonful of pure 
glycerine to each bottle of food prepared. A teaspoonful of malt-extract 
will sweeten and also relieve constipation. 

Excess of P rote ids. 1 — A careful observation of the stools would easily 
show whether the albuminoids are in excess, for they are usually present 
in the form of curds. This condition is usually associated with constipa- 
tion, and the indication would be to cut down the quantity of proteid 
administered. 

Undigested curds due to excess of proteids and excessive fats are a 
frequent cause of colic. Irregular feeding, too frequent or over-feeding, 
are the commoner causes. The majority of cases of colic are seen in bottle- 
fed babies. This is usually due to milk which is too acid or superheated 
milk, as in prolonged sterilization. In the latter manner of treating milk 
the casein is rendered very difficult to digest, and frequently results in 
intestinal fermentation, causing colic. 

Colic in Breast-fed Babies. — If colostrum continues and the milk does 
not assume normal conditions, colic may result. Colic is frequently seen 
during menstruation of nursing women. Pregnancy occurring during lac- 
tation usually causes colic. 

Differential Diagnosis. — We must be extremely careful to exclude the 
pain of intussusception, the pain from gall-stones, the pain of appendicitis. 
or the pain of a strangulated hernia. The absence of fever, the disappear- 
ance of the symptoms by the regulation of the diet, the flushing of the 
colon to remove the offending cheesy debris, will materially aid in strength- 
ening the diagnosis. 

Infant J., eleven months old. bottle-fed. cried and suffered with pain from 
one to two hours after taking his feeding. The temperature was 101° F., rarely 
higher. The infant would scream for a few minutes at a time, then expel flatus per 
rectum, and be apparently relieved. He would be cheerful and play for a short 
time when another paroxysm of pain would come on and start him screaming again, 
until flatus was expelled. Relief was immediately given when the rectum and 
colon were flushed with warm water to which several ounces of glycerine had been 
added: temperature. 115° F. Anti-fermentative-, such as rhubarb and soda mixture, 
or several grains of calcined magnesia, invariably relieved the child and prevented 
intestinal fermentation. 

The treatment of colic is simple when the cause is known. The quick- 
est method of relieving colic is to give an enema of soap and water or of 
warm chamomile tea. I usually take an ounce of German chamomile 
flowers and steep them in a quart of boiling water from ten to fifteen min- 
utes, then strain. The injection is to be given in the same manner as 
has been described in detail in the chapter on "Constipation."' My method 



1 Read also article on •'"Proteid Indigestion," in chapter on •"Breast Feeding, 
Part III. 



[NTESTIN \l. i OLK 



295 



is to allow 1 or 2 pints of chamomile tea at a temperature of LOO* to L10 

F. (no hotter) to flow slowly into the rectum, and by all means the colon. 
When the colon is thoroughly flushed with this warm tea, and emptied of 
its fasces, it is usual for the attack of colic to cease, in addition to washing 
the colon, it is a good plan to apply a small hag of either chamomile Sowers 
or slippery elm hark, or ground flaxseed meal. To do this, I make a hag 
of cheese-cloth capable of holding from 1 to 2 ounces, and then fill it with 
one of the above-mentioned ingredients; sew the hag shut when filled, and 
heat it before applying to the abdomen. Several of these bags can be made 
and kept in readiness, so that they can be applied quickly. It is a good 
plan to have one heating on the stove while another is on the abdomen. 
These little bags are very soothing, and we are frequently rewarded by 
having the infant not only expel wind shortly after they are applied, but 
also fall asleep. 

Massage. — During an attack of colic gentle massage with warm sweet- 
oil or melted vaseline or lard will certainly be very comforting to the child. 
My plan is to take a bottle of oil, warm it by placing it in a kettle of warm 
water, and then to pour it on the abdomen. The distended abdomen should 
then be thoroughly kneaded until the gas is expelled. Then the warm 
applications mentioned above can be applied. 

Drug Treatment. — If the colic originated from a fermentative dys- 
pepsia, then treatment must be directed to the stomach. For this purpose 
antifermentatives. like the mistura rhei et soda?, should be given in doses 
of y 2 to 1 teaspoonful, diluted with water, every two or three hours until 
there is a thorough evacuation. Very good results will be found, after the 
bowel has been cleaned with the quart of chamomile tea previously men- 
tioned, by administering from 5 to 10 grains of bismuth ; I prefer to use 
betanaphtol or the subnitrate; %-grain doses of resorcin will also be found 
useful. Paregoric in closes of 15 drops to "V2 teaspoonful should be admin- 
istered with great caution to children of six months or older. It is under- 
stood that no physician will forget the danger of giving repeated doses of 
paregoric or permitting the same to be administered by incompetent people 
not aware of the dangers of the drug habit. The author has not only seen 
distinct opium poisoning follow the use of paregoric, but has also had occa- 
sion to see the distinct opium habit in very young children. This was 
reported by me in a paper read before the Xew York County Medical 
Society, Januarv 22, 1894, which was published in e.rtrnso in the Med- 
ical Record of February IT, 1894. For an infant during the first few 
months, it is hardly safe to give more than 5 drops of paregoric, repeated 
in an hour if there is no relief. Another drug that has served the author 
ver\- well is Hoffmann's anodyne in doses of from 1 to 5 drops, repeated 
in an hour if necessary. For an infant up to two months 1 drop per dose; 
from two to four months, 2 drops per dose; four to six months, 3 drops; 



296 DISEASES OF THE INTESTINES. 

six to nine months and until 1 year of age. -I drops; children from 1 to 
2 years, 5 drops. This is to be given in a teaspoonful of sterilized water. 
Another valuable drug, and one that is to be given cautiously, and in the 
same doses as Hoffmann's anodyne, is spirits of chloroform; never should 
more than from 1 to 4 drops be given to a child up to 1 year of age. and 
younger children less in proportion. I cannot favor the administration of 
nauseating or foul-smelling drugs, such as asafcetida. We must try to 
cater to an infant's taste, especially so when in pain. 

An excellent preparation to relieve colic is calcined magnesia, or milk 
of magnesia, made by Phillips. 1 Hare's "System of Medicine" contains 
an article by Stewart advocating its use. It has served the writer very well . 
especially in young infants, where acidity was prevalent. A half-teaspoon- 
ful several times a day was enough in some cases, while others required 
several teaspoonfuls during the day. It is valuable where constipation 
exists, and can be added to the bottle of food. 

Borborygmus (Rumbling Noises). — Children frequently have rum- 
bling noises which are troublesome. A girl recently under treatment of the 
writer had this trouble for several years. The noises were so loud that they 
could be heard in the adjoining room. They were aggravated by deep 
inspiration. Frequently eructations of gas would afford temporary relief. 
This condition is met with in ectasia or in ptosis of the stomach. In the 
case of gastroptosis above mentioned, a tight-fitting abdominal bandage 
afforded relief. Anti-fermentatives : Milk of magnesia in teaspoonful 
doses is beneficial: powdered charcoal in 2- to 5- grain doses is also useful 
when taken shortly before meals. 

Acute Ixtestixal Indigestion. 

This disturbance originates in the duodenum. As a rule that which 
the laity describes as a "bilious attack" is an acute or chronic condition 
which originates from food which has not been properly digested. 

Symptoms. — This condition is very rare in young infants, but is fre- 
quently met with in later childhood. Headache is a prominent symptom, 
associated with pain in the abdomen and usually sour eructations. The 
breath is foul ; the tongue is coated. Sometimes undigested particles of food 
will be seen in the stools (lientery). The temperature ranges between 100° 
and 101° F., rarely higher. Either diarrhoea or constipation may be pres- 



1 Philips's Milk of Magnesia — Eydrated Oxide of Magnesiiun (MgH 2 2 ). — A 
teaspoonful of Philips's Milk of Magnesia is equivalent in acid-neutralizing power 
to 4 ounces of lime water, or 10 grains of sodium bicarbonate. It will neutralize 
nearly twice its volume of lemon juice. Each fluidounce represents 24 grains of 
magnesium hydrate. Dose: From a teaspoonful to a tablespoonful, according to 
age — increased or diminished at discretion. Dilute with equal quantity or more of 
water. 



CHRONIC [NTESTINAL [NDIGESTION. 297 

ent. If very little bile is passed the stools may be clay-colored. Rarely 
jaundice is present. 

The prognosis is always good. 

Treatment. — Remove the cause if possible. It is necessary to study the 
diet of the child and exclude undigestible food which might cause these 
attacks. During an acute attack 5 drops of peppermint in a tablespoonful 
of hot water, or 3 drops of Hoffmann's anodyne may be given to relieve 
colicky pains. 

In an article in Pediatrics on "Gastro-intestinal Indigestion in Chil- 
dren," Dr. S. Henry Dessau, of New York, says that when spigelia is added 
in moderate doses to the tonic-laxative as in the formula given below, it 
appears to exercise a most beneficial influence in arresting the immoderate 
secretion of mucus, diminishing flatulence, relieving the sighing respira- 
tion, and removing the many nervous phenomena. 

The formula he employs, which may be called a working basis, is com- 
posed of: — 

IJ Ext. spigelia, fld 2 fluidrachms 

Ext. senna., fld * •:- 2 fluidrachms 

Ext. cascara, fld. : 1 fluidrachm 

Tr. mix vomica 1 fluidrachm 

Tr. cinchona comp 4 fluidrachms 

Syr. sarsaparilla comp., ad 2 fluid ounces 

M. Sig.: 1 drachm ter in die. 

The diet should exclude milk during the acute attack for at least 
twelve to twenty-four hours, and thin soups or broths and weak tea can. 
be given instead. 



Chroxic Intestinal Ixdigestiox (Duodenal Catarrh: 
Mucus Disease). 

This condition is always associated with a chronic derangement of the 
stomach. It is usually a functional disturbance and is one of the most 
difficult conditions to treat in children. 

Etiology. — This is usually obscure, although it follows exhaustive dis- 
eases such as typhoid, diphtheria, or other infectious diseases. The most 
frequent cause is improper food, unsuited for the age and development of 
the child. 

Symptoms. — As a rule gastro-enteritis precedes this condition for 
months, in each and every case. The stool shows a tendency to looseness 
and mucus is found covering the faeces. The mucus is seen in shreds and 
masses at times covering the faecal matter. Such children are usually 
backward in development. They are very irritable, tire easily, and looe 
in weight. 



298 DISEASES OF THE INTESTINES. 

As a rule the abdomen is distended. There is no fever. The appetite 
varies and is poor. The liver does not functionate properly, and in some 
cases very little bile is secreted, giving rise to clay-colored stools. The skin 
is dry. 

Diagnosis. — The only condition which might resemble chronic intes-- 
tinal indigestion is general tuberculosis. The absence of cough, the ab- 
sence of fever, and the absence of physical signs in the lungs should help 
to exclude tuberculosis. The diagnosis will be more readily made when 
previous gastric or gastro-intestinal derangements are taken into account. 

Prognosis. — This is usually good, even though these attacks may ex- 
tend over years. If, however, rapid emaciation and general weakening of 
the heart exists, the prognosis becomes grave. 

Treatment. — Dietetic Treatment: This is the most important part 
of the treatment and requires very careful consideration. Excessive fats 
and sugars should be avoided. Light meals rather than heavy should 
be ordered. Give predigested food if required. Whey, skimmed milk, 
zoolak, thin cocoa, chicken broth, beef broth, clam broth, soft-boiled egg, 
fish, oysters, raw scraped steak, apple sauce, baked apple, to be varied with 
other well stewed fruit, should be given. Avoid all fresh bread. Eusk 
(zwieback) may be given. Give all green vegetables in season. Avoid all 
heavy cakes, pies, and puddings. If this light diet is continued for several 
months great improvement will be noted. The ultimate care will depend 
on restricting the diet to nutritious and very easily digested food. 

Medicinal Treatment. — Give nux vomica, 1 to 3 drops, three times a 
day, before meals. Or: — 

IJ Acid hydrochlor. dilut 1 ounce 

Five minims three times a day, after meals. 

Pay careful attention to the bowels; give a laxative if necessary. If 
severe anaemia exists then give: — 

IJ Tr. ferri acet. seth 1 ounce 

Ten drops, three times a day. One hour after meals. 

This has been found to be the best form of iron in the management of 
this condition. 

A girl, 8 years old, was breast-fed in infancy and appeared apparently 
healthy. Her dentition, walking, and talking normally developed about the end 
of the first year. During the second year she suffered with measles. When 4 years 
old she had an attack of acute milk poisoning, resulting in gastroenteritis. From 
this time on she has not been in good health. She complained of headaches, naunea, 
and anorexia. She has a foul breath, and is very anaemic. She does not seem to 
thrive. The slightest imprudence in eating causes gastric symptoms. Her abdomen 
is large and gas is frequently expelled per rectum. She is always languid. The 
temperature is normal, the pulse-rate feeble, it usually ranges between 90 and 



ACUTE MILK 1NKKCTION. 



%Y.) 



100. She does not sleep well, talks in her sleep and tosses about. Under a rigid 
diet, excluding pure milk, and giving diluted milk, whey, thin soups, soft boiled eggs, 
and fruit, improvement was noted. The interval of feeding was restricted to five 
hours, so that the child was fed three times a day. A daily movement of the bowels 
was insisted upon. One half-teaspoonful of phosphate of soda in a teacup of warm 
water was given when the child was constipated. Five drops of acid hydrochloric 
dilute was given three times a day. The case improved and the child is in a good 
condition to-day. 



Acute Milk Infection (Ciioleriform Diarrhcea: 
Cholera Infantum). 1 

In bottle-fed children, especially among the poorer classes, acute milk 
poisoning is frequently seen during the summer months. This is due 
mainly to the chemical or toxic product developed in the milk. The heat 
of the summer rapidly decomposes milk, and large quantities of bacteria 
multiply and generate their toxic products. When such milk is fed to 
infants they show the effect of the toxin very rapidly. Park found that 
when milk was first received from the farms it contained from 10,000 to 
20,000 bacteria in each cubic centimeter. On the second day the bacteria 
had so increased that there was between 10,000,000 to 30,000,000 per cubic 
centimeter. 

Langermann 2 found that a sterilized milk mixture which contained 
roughly from 30 to 40 micro-organisms when taken by the infant, con- 
tained from 4000 to 6000 one and one-half hours later when taken from 
the infant's stomach. 

In healthy infants nursed at the breast he found the same number of 
bacteria in the stomach contents as he did in the stomach contents of in- 
fants taking sterilized milk. 

The stomach contents of infants suffering with dyspepsia contained 
many more organisms that that of healthy children. 

He found that hydrochloric acid acts as an anti-fermentative. Thus it 
appears from his experiments that numerous organisms are present and 
flourish in the stomach of infants under normal conditions, being derived 
from the food and also from the mouth. 

Summer diseases, particularly entero-colitis and cholera infantum, will 
appear just as readily in breast-fed children who are improperly managed 
as in bottle-fed children. By improperly fed children I mean too frequent 
feeding or the feeding of breast-milk which is unsuited for the infant, 
because of excessive fats or an excess of proteids. This has already been 
described in detail in the chapters on "Breast and Bottle Feeding." 



ir The bacteriology is described in the following chapter on "Subacute Milk 
Infection." 

2 Jahrbuch fur Kinderheilkunde, Band xxxv, Heft 1 and 2, p. 88. 



300 



DISEASES OF THE INTESTINES. 



Pathology. — There is extreme emaciation of the entire body affecting 
muscles and fat. The fontanel is depressed. The eyes are sunken. The 
elasticity of the skin is gradually lost ; the skin hangs in loose folds. The 
body resembles an advanced form of tuberculosis. Minute haemorrhages 
are found associated with intense congestion in the stomach and intestines. 
The evidence of catarrh is everywhere seen. There is an excessive secretion 
of mucus in the larger intestine ; in the colon ulcers will be found. 

Ashby and Wright describe a general distention of the net-work of the 
capillaries situated in the mucous membrane of the intestine. The same 
condition is found in the submucosa, in the villi, and between the tubules 
and crypts of Lieberkuhn. "The central portions of the solitary glands 




Fig. 84. — A Case of Acute Milk Poisoning Having Vomiting, Diarrhoea, 
Mucous and Bloody Stools, General Emaciation, Acute Cholera Infantum, and 
Dysentery. ( Original. ) 



are softened, or, the softened portions having been discharged, the remains 
of the glands appear as sharply cut ulcers, although the sinuses of the brain 
are found distended with blood. Occasionally cerebral anaemia may exist." 
Meningitis is rare. 

Causes. — Two varieties of micro-organisms are constantly present in 
the intestinal tract of healthy children. They are described in detail in 
the article on "Bacteria of the Intestine," and also in my book on "Infant 
Feeding in Health and Disease," page 39, Third Edition. We rarely see 
this condition in breast-fed children, unless there is present a subnormal 
condition due to atmospheric conditions. Overfeeding and irregular feed- 
ing also invite this condition. 

See article published by me in the Medical Record, July 13, 1895, entitled 
"The Treatment of Summer Complaint, or Gastro-enteritis Catarrhalis Acuta, 
Including Cholera Infantum in Children." 



[*E MILK IXFK< 1 



301 



The etiological factors can be briefly outlined as follows: — 

1. Food, improper quantity and quality of the same, be it breast-milk 
or hand-feeding. It is a well-known fact, cited by Jacobi among others, 
that breast-milk can also cause this disease. 

2. The most frequent cause is certainly improper bottle-feeding, 
wherein food unsuited to the infant's digestive abilities is continued, in 
spite of - efforts to warn us, as frequently manifested by either 
vomiting or diarrhoea, or both. 

3. Milk from mothers suffering with tuberculosis or syphilis. Preg- 
nant women, menstruating and all anaemic women, a ;eh poor milk 
that gastro-enteric derangements are exceedingly common. 

4. The influence of the weather on digestion, especially the extreme 
heat of summer. 

5. Improper disinfection of the nipples after feeding, and consequent 
decomposition and formation of micro-organisms, causing infection; all 

_itary conditions deleterious to the healthy child. 

An important point to remember is that very many diseases have 
symptoms resembling cholera infantum and must be carefully differen- 
tiated; for example, typhoid fever occurring in midsummer may simulate 
this disease and give rise to symptoms which greatly resemble cholera in- 
fantum. We occasionally see children having diarrhoea, vomiting, and 
fever in whom on palpation a tenderness in the ileo-caecal region can be 
palpated. Such cases may have appendicitis and still show all the symp- 
toms of cholera infantum. 

From reliable statistics in Xorway the mortality ranges from 8.5 to 
10.5 (breast-feeding only), while in Bavaria the mortality is about : r 
cent, (mostly • bottle-feeding), children being brought up chiefly on 
farinaceous foods. Out of 400 Heaths of children from summer diarrhoea, 
Minaret, in Bavaria, observed 96 per cent, were artificially fed. 

Table No. 54. — Population, Deaths and Ikath.-Ea.iis of Children under Five Years vf 
During June. July and August, from 1891 to 1903 in [old) Xew York City. 



Kim; 


Population. 


DeaHni 




1801 


IS?. 703 


5,945 




1892 


194.214 


6.6:2 


136.1 




199. SS6 


5,899 


117.9 




805,723 




112.5 


1895 


213,963 


6.1 S3 


116.1 


IS* 6 


21S.444 


5,671 


1 93 - 


1897 


828.383 


5,041 






226^515 


5. -~ 




1899 


843 


4,689 


81.2 


1900 


- 5,386 


4." 


77.5 


1901 


240.166 


4.642 


77.3 


1908 


946 - 


#,381 


71.6 




2-50.518 




64.5 



302 DISEASES OF THE INTESTINES. 

Table No. 55. — Population, Deaths and Death-Bates of Children under Five Years of Age, 
from 1891 to 1903 in (old) New York City. 



Year. 


Population. 


Deaths. 


Death-Kate. 


1891 


188,703 


18,224 


96.6 


1892 


194,214 


18,684 


96.2 


1893 


199,886 


17,865 


89.4 


1894 


205,723 


17,558 


85.3 


1895 


212,983 


18,221 


85.6 


1896 


218,444 


16,807 


76.9 


1897 


222,387 


15,395 


69.2 


1898 


226,515 


15,591 


68.8 


1899 


230,842 


14,391 


62.3 


1900 


235,386 


15,648 


66.5 


1901 


240,166 


14,809 


61.6 


1902 


245,201 


15,019 


61.2 


1903 


250,518 


13,741 


54.8 



The above populations previous to 1896 represent estimates based on 
the proportion of children under 5 to total population, as existed at the 
census of 1895, to wit: 11.37 per cent.; and from 1896 on, to the pro- 
portion as existed at the census of 1900, to wit: 11.46 per cent. 

The author desires to thankfully acknowledge the kindness of Dr. 
William H. Guilfoy, of New York Health Department, for furnishing the 
above statistics. 

Harry G., ten months old, bottle-fed, was brought to me with a history of 
vomiting, high fever, and diarrhoea. The temperature was 104° F. The stool was 
green and contained mucus and curds, and had a very foetid odor. The stools were 
as frequent as twenty in twenty-four hours. There was a great deal of flatulence, 
the abdomen was distended, and there was constant tenesmus. The mouth was 
dry, the tongue had a whitish fur coating, and in the mouth small patches of 
stomatitis could be seen. The tongue protruded constantly and when liquids were 
given they were taken ravenously. The mother stated that ordinary grocer's milk 
had been used, and that she believed the milk had turned sour "after a thunder 
storm." The diagnosis of acute milk infection was made. The stomach was washed 
by the use of 1 quart of saline solution. Two drachms of castor oil was ordered, 
and one hour later the rectum and colon were flushed with 1 quart of chamomile tea. 
All milk was stopped. No food was given for six hours. A bland diet of sweetened 
rice water and whey was then given in quantities of 4 ounces every two hours. As 
a stimulant, 15 drops of whisky was given with Vioo grain of strychnine every three 
hours. The child improved, and three days later 1 ounce of milk, with 7 ounces of 
rice water, was given every three hours. The milk was gradually increased every 
other day, and the rice water decreased. The child recovered. 

Symptoms. — The two cardinal symptoms are (a) vomiting, (b) diar- 
rhoea. In some instances the first evidence of this infection will be fever. 
The temperature may be as high as 103° to 105° F. There will be intense 
thirst. There is no appetite. The infant will refuse its bottle, and if 
forced to take it will immediately throw it off. Bile, mucus, and sour 



ACUTE MILK [NFECTION. 



303 



smelling curd form the bulk of the vomit. The abdomen is usually dis- 
tended. There is a great deal of flatulence. The stool is watery and green- 
ish in color, with a very foul odor. When the diarrhoea continues for sev- 
eral days, the temperature may become subnormal and the infant's fore- 
head may be covered with a cold, clammy perspiration. The extremities 
are usually cold. The child will sink very rapidly, owing to the amount 
of exhaustion. The body is constantly drained by the diarrhoea. Imless 
the clinical picture is recognized and proper treatment instituted, the 
infant may sink into a coma and have convulsions, followed by death. 

The following case illustrates acute milk poisoning in an infant less than 1 
year old. The infant was bottle-fed and received the food daily, modified, from a 
milk laboratory. This food seemed to agree until the time of the present illness. 
The child was under the treatment of Dr. John Logan and Dr. J. Martinson, both 
of Xew York. The case was seen by me in consultation after several days' illness. 
The infant was vomiting and had greenish, mucous stools. There was severe tenesmus. 
The infant showed severe prostration and was apparently comatose. The fontanel 
was sunken. The pulse was very feeble. The circulation was poor and the extremi- 
ties cold. As no food was retained, in addition to the amount of toxin in the 
circulation, the heart's action became weaker and weaker. It was very difficult to 
rouse this child. In spite of high saline colon injections, the child died of 
exhaustion associated with general toxaemia. 

Diagnosis. — The diagnosis of this condition is extremely easy. It is 
usually aided by the clinical history. The disease usually occurs in sum- 
mer, although milk poisoning can take place during any time of the year. 

Differential Diagnosis. — Sunstroke may sometimes be confounded with 
cholera infantum, but the continued diarrhoea in cholera infantum, and 
its history, should aid in eliminating this condition as a factor. Asiatic 
cholera shows symptoms similar to cholera infantum. The presence of the 
comma bacillus in the stools will easily establish the presence of Asiatic 
cholera. 

The prognosis depends on the infant, its surroundings, and the amount 
of infection, and the length of illness. An infant having good vitality and 
being given a careful diet and stimulation with proper hygienic treatment 
certainly has more chance than one left in the city amid poor surround- 
ings with faulty hygiene. 

Treatment. — If the infant is breast-fed discontinue the breast at least 
twenty-four hours. During this time rice water, barley water, albumin 
water, or very weak tea may be given. Diluted coffee is frequently ordered 
by me when evidence of heart weakness exists. If the acute symptoms of 
vomiting and diarrhoea have been stopped by appropriate treatment, then 
the breast may be permitted once every six or eight hours, the alternate 
feeding to consist of rice or barley water, as previously described. In other 
words, we must return gradually to milk feeding. If acute symptoms return 



304 DISEASES OF THE INTESTINES. 

when the breast-milk is given, then it is a question as to whether or no the 
breast should be entirely withheld. Whey is a useful substitute when milk 
is not well borne. 

Bottle-fed Infants. — Stop all cows' milk. 

A good p'an is to feed with intervals of three and four hours between 
each meal, and if the usual amount of feeding was six or eight ounces, then 
it is a good plan to give but four or six ounces, of either rice, barley, or 
farina water. Albumin water, made by adding the white of a raw egg to a 
wineglassful of sterilized water and a pinch of salt, is very good to allay 
thirst, besides adding to the nutrition of the child. Ice-cold tea (the ordi- 
nary black and green tea mixed) can be given ad libitum. 

Hygienic Treatment. — Cold bathing or bathing in cold or lukewarm 
water, to which some sea salt has been added, is very advantageous; the 
child should be put into the largest and coolest room in the house, the tem- 
perature to be from 68° to 75° F. If sea air is obtainable, then it is 
wise to remove the child to the seashore, or at least to insist on daily excur- 
sions. 

Cold applications to the head and an ice-bag over the fontanel, cold 
towels changed every fifteen or thirty minutes over the abdomen, will tone 
up the nervous system in addition to reducing the temperature. I am 
a decided opponent to antipyretic drugs, and never use antipyrin or phenace- 
tine, but invariably resort to hydropathic measures for the reduction of the 
temperature. Sponging of the body with alcohol and water is very grateful 
and refreshing, besides a good antipyretic measure. If cyanosis and cold 
extremities exist, then it is wise to resort to hot mustard baths to stimulate 
the circulation. 



STOHLMANN, PFARRE &. CD. N.Y. 

Fig. 85. — Exact Size of Catheter Used for Irrigating a Very Young Infant. 

Having noted the various causes of summer diarrhoea, chief among 
which is improper feeding and its resultant diarrhoea, the first thing to do 
is to cleanse the stomach and bowels. This can be most readily accomplished 
by:- 

Stomach Washing. — To do this, I take a No. 10 soft flexible (rubber) 
catheter (No. 8 for a younger infant), having more than one opening, and 
attach it to either a 2-quart glass irrigator or a 2-quart rubber fountain 
syringe. It is far better to use rubber tubing and a glass funnel, as we can 
then easily watch the liquid enter, and it is also more practical, as it can be 
kept clean more readily. For irrigating the stomach I use the following 
solution : — 

Ifc Table salt 1 teaspoonful 

Boiled water 1 quart 



ACUTE MILK [NFECTION. 



305 



The above quantity for one washing, to be used until the gastric con- 
tents flow away clear. To introduce the tube it is pushed through the 
mouth, gently bul rapidly against the pharyngeal wall, into the oesophagus, 
until the stomach is reached. It should not be anointed with oil, as we 
normally have so much mucus present that we have Nature's own lubrica- 
tion. Having introduced the tube, T raise the irrigator or funnel or 
fountain syringe, which lias been previously filled with 1 quart of the salt 
solution mentioned above, and hold the same about one to two feet over 
the child's head — no higher. The temperature of the water should be be- 
tween 100° and 105° F. If there is severe irritability of the stomach, or 
a tendency to nausea and vomiting, then it is a safe plan to attach the 
catheter to a long tube, ending in a funnel, and using but one-half to one 
pint of the salt solution; allow it to enter the stomach slowly. We can 
syphon off the contents of the stomach by lowering the funnel below the 
level of the stomach. After emptying the same we can again fill the fun- 
nel, and allow the salt solution to 'flow into the stomach, and so this process 
of syphoning can be repeated until the gastric contents flow away fairly 
clean. 

It is a good plan not to continue the washing of the stomach, unless 
urgent symptoms of gastric fermentation or possibly vomiting of food call 
for the same. It is my plan to wait at least one or two days and note the 
effect of the stomach washing before repeating it. 

Having cleaned the stomach, it is a good plan to prescribe rest, and to 
insist on leaving the child several hours, without giving food of any kind. 
I usually order a small quantity of an alkaline water, either Seltzer or 
Vichy, Apollinaris water, or plain boiled (sterilized) water. A tablespoon- 
ful of lime water, several times a day, independent of food, is also advan- 
tageous. 

In all forms of diarrhoea milk must be discontinued. The details of 
feeding have already been given. 

When we find a decided objection on the part of the patients or their 
parents to the above method of cleansing the stomach, then we must resort 
to:— 

Drug Treatment. — For this purpose a large dose of calomel, 14 of a 
grain for a child 1 year old, is given every two or three hours, until watery 
rtools are produced, and this is followed on the succeeding day by two or 
three doses (a teaspoonful each) of castor-oil. The tendency to constipation 
following a dose of castor-oil makes it a valuable remedy in all forms of 
diarrhoea. Bismuth is the sovereign remedy; I have used the subcar- 
bonate, subnitrate, salicylate, and betanaphthol bismuth, and find the latter 
an extremely valuable preparation. In doses of 2 to 5 grains every few 
hours, mixed with a little boiled water, it not only agrees very well with 



306 DISEASES OF THE INTESTINES. 

children, but seems to exert a healing effect in that form of bacillary diar- 
rhoea which is met with in the acute catarrhal gastro-enteritis. 

Salol in doses of 1. 2. and 3 grains, for each year respectively, is an- 
other valuable remedy: so also is resorein, in doses of 14 to 1 grain for 
a child 1 year old, three or four times a day. It is advisable not to add 




Fig. 86. — Stomach Washing. Introduction of the catheter. (Original. 

sugar for sweetening, but only glycerine; the latter, however, in very small 
quantities, as it has a tendency to loosen the bowels. 

Xitrate of silver in doses of a r 50 grain for a child 1 year old, repeated 
every three or four hours, is valuable in some cases. 

Tannalbin and tannigen in doses of from 1 to 10 grains seem to act 
well in some cases, poorly in others, but are well worth trying in those 
desperate cases in which we change the drugs, if they are ineffectual. 

Hypodermic Medication. — In forms of collapse, where constant diar- 
rhoea has drained the system, it is a good plan when the extremities are cold 



ai i 'n-: Aiii.K i\ii:< tion. 



307 



to give hypodermic injections of 10 to 20 drops of whisky. Sulphuric ether 
ran also be administered hypodermically in the saint' dose as whisky. An- 
other valuable stimulant is musk; 2 to .'5 drops of tincture of musk admin- 
istered hypodermically every hour will frequently rouse the circulation. 

When this form of treatment proves unsuccessful, and the condition of 
collapse continues, then a good plan is to resort to hypodermoclysis. This 




Fig. 87. — Stomach Washing. Syphoning off the gastric contents (Original. ) 



consists of introducing a long aspirating needle (previously sterilized by 
boiling) into the loose connective tissue of the abdomen, and allowing sev- 
eral pints of the normal saline solution, containing about 7% grains of 
table salt to a pint of water, temperature 100° F. ? to flow in subcuta- 
neously. It is remarkable to note how much liquid can be introduced in 
this manner, and some of the most desperate cases of collapse will respond 
very rapidly. I have seen children who previous to this injection were 
pulseless suddenly brighten up. and within a few minutes show a distinct 
radial pulse. Too much care cannot be bestowed on the sterilization of 



308 DISEASES OF THE INTESTINES. 

every part of the apparatus, and the absolute cleanliness of the water to he 
used for this purpose. 

Rectal and Colon Flushing. — It is advisable to irrigate the colon and 
rectum by placing the child on its left side, introducing a flexible rubber 
tube anointed with carbolized vaseline. Having passed the external sphinc- 
ter. I invariably allow the water to flow into the rectum in order to balloon 
the same, and then continue to push the tube beyond the rectum into the 
colon. A little difficulty is sometimes encountered, owing to the spas- 
modic contraction of the muscles, but if we wait a short time, using a little 
patience, the tube can easily be pushed into the colon. The method pur- 
sued is the same as described previously in irrigating the stomach, excepting 
that we do not seek to syphon off the contents of the bowels, but rather allow 
a pint or a quart of the warm saline solution to nu c h the bowels, and in 
this manner wash away as much of the offending debris as exists within the 
bowels. I have frequently used cold water, but I find much greater benefit 
from the use of a warm solution of the temperature of 105° F. 

Besides table-salt solution, a 1 per cent, boracic acid solution can be 
used: so also can a 1 to 10.000 solution of bichloride of mercury. A solu- 
tion of 10 grains of tannic acid to a pint can also be used, and a 1 to 1000 
solution of nitrate of silver is indicated in other cas s. 

Some of our cases require irrigation once in twenty-four hours for one 
week, and others again are so greatly improved after one rectal washing that 
it is not necessary to resort to it again. 

Starch injection-, made by adding 2 tablespoonfuls of the ordinary 
starch to a quart of warm water of a temperature of 105° F.. may be given. 
They are very advantageous, as the colon changes starch into dextrin, 
which is easily absorbed. Thus not only does the latter cleanse, but it is 
also nutritious. Large quantities of saline solution can be introduced 
into the circulation by means of colon washing, thus adding to the volume 
of the blood. I therefore lay great stress on this form of treatment, as 
one of the most valuable for this depleting condition. Thromboses can 
frequently be avoided by these injections. 

When severe tenesmus exists, painting of the lower end of the rectum 
with a 2 per cent, solution of cocaine is frequently very advantageous. Pro- 
lapse of the rectum and anus can frequently be prevented by applying a 
strip of zinc oxide plaster from one buttock tightly to the other, so that the 
buttocks will support the bowel and mechanically prevent its protrusion. 

Subacute Milk Ixfectiox (Sumaiee Diaeehcea). 

In this condition we have a gastro-intestinal disorder due to the toxins 
generated from the bacteria in milk. This usually occurs during the sum- 
mer months, when there is great humidity in the air. The symptoms are 
not so severe as those seen in the acute form of milk infection. It is usually 



SI BACUTE MILK [NFECTION. 



309 



met with among the poorer classes who buy a cheap milk which usually 
contains millions of bacteria. Victor Vaughn, of Ann Arbor, Mich., in a 
letter to me, stated that although it is possible to destroy all bacteria by 
repeated and continued sterilization, he found it impossible to destroy the 
toxins generated in milk even though the temperature was raised to 300° F. 

Cause of Infant Mortality. — The weeds eaten by cows in their summer 
pastures are responsible for many cases of gastro-intestinal disease. Many 
of these weeds are poisonous and their juices pass into the milk. In 
support of this theory Hauser gives the statistics of mortality in a number 
of districts in his experience, classifying them by the soil and the weeds 
that grow by preference on certain soils. His tables indicate a lower death- 
rate on the granite and sandstone foundation. He contends that sys- 
tematic eradication of weeds from pastures would banish certain gastro- 
intestinal affections in infants. 

Bacteriology. — Bacteriological 1 investigation of summer diarrhoea com- 
menced when Escherich, in 1886, published his work on the intestinal 
bacteria of infants and their relation to the physiology of digestion. 
Lcsage, Hayem, and Baginsky contributed further researches, but the most 
important and exhaustive researches were made by Booker from 1886 to 
1897. As the result of these he called attention to three principal forms 
of summer diarrhoea, based on a correspondence of their clinical, anatom- 
ical, and bacteriological features: (1) dyspeptic or non-inflammatory diar- 
rhoea, in which the obligatory milk-fgeces bacteria are found, chiefly the 
bacillus coli communis, the bacillus lactis aerogenes appearing in smaller 
numbers; (2) streptococcus gastro-enteritis, in which there is a general 
infection and ulceration of the intestine, with streptococci as the pre- 
dominating forms, some bacilli being present as well; (3) bacillary gastro- 
enteritis characterized by a general toxic condition with less intestinal 
inflammation, and the presence in the stool of several varieties of bacilli, 
the proteus vulgaris being the most common. 

Escherich studied the streptococcus cases more closely (1897-1899) 
and found the cocci numerous and in almost pure culture in the stools in 
acute, severe cases, while it was possible to isolate them from the urine 
and the blood during life and from the viscera after death. Clinically, the 
symptoms vary much in the mild and the severe cases; the stools may be 
watery and contain much pus and blood. Staphylococci have also been 
found in diarrhceal stools, but much less frequently than streptococci. Later 
Escherich described cases of dysentery due to a virulent colon bacillus. 
Valagussa found a bacillus belonging to the colon group and identical with 
that isolated by Celli and Fiocca from cases in Italy and Egypt. In 1898 
Shiga, in Japan, described the bacillus dysenteriae, an organism more nearly 



x An editorial in Archives of Pediatrics, August, 1901. 



310 DISEASES OF THE INTESTINES. 

related to the typhoid than to the colon group, and Flexner found the same 
bacillus in one form of acute dysentery studied in Manila. Both Celli and 
Escherich tried to identify the bacillus they described with that of Shiga. 
The bacillus pyocyaneus has also been found in the stools of cases of 
epidemic infantile dysentery. It is evident, then, that no specific bac- 
terium of gastro-enteritis has been found; there is one form in which the 
streptococcus is the predominating organism, and the bacillus dysenteriaB 
may possibly be proved to be the cause of epidemic dysentery both in chil- 
dren and in adults. 

Pathology. — -Inflammatory lesions and ulcerations can be seen in the 
colon. It is rare to find the duodenum and jejunum involved. The micro- 
scopical findings of the stool show numerous bacteria, epithelial cells, de- 
tritus, and occasionally blood. Sometimes particles of food are also seen. 

Symptoms. — Vomiting and diarrhoea as in the acute form are the main 
symptoms. If an infant has just recovered from an acute milk infection 
and is placed on milk feeding too soon, a relapse frequently occurs, which 
is a subacute infection. The stools are greenish and resemble those de- 
scribed in the acute form. There is a loss of appetite, a coated tongue, and 
the temperature ranges between 101° and 105° F. ; at times the tempera- 
ture may be normal or subnormal. The infant does not want to be dis- 
turbed, and is very irritable. The irritation and tenesmus accompanying 
this diarrhoea usually causes the rectum to prolapse, and from the constant 
discharges of the bowel the anus and buttocks are excoriated. An eczem- 
atous eruption frequently is seen between the thighs. Local infection of 
the skin and lymphatics, by the presence of the pyogenic bacteria, some- 
times causes furuncles. 

Diagnosis. — This is usually made when the history and symptoms are 
carefully noted. It is much milder than cholera infantum. The tempera- 
ture is lower-, the vomiting less, and the prostration not so marked. 

Jonah W., seven months old, twin baby, bottle-fed, had been constipated since 
birth. There was a slight cough. The child had beaded ribs, cranio tabes, and bald- 
ness of the occiput. Since one month he had vomiting and diarrhoea. This had 
improved and disappeared entirely. The child was given milk, and ten days after 
the milk diet was commenced the symptoms of vomiting and diarrhoea again appeared, 
but in a milder form. Several furuncles were found on his scalp. Owing to the 
intolerance of milk, whey was given in the same quantity and frequency as the milk 
was formerly given. Rice water, barley water and thickened pea soup was allowed. 
Toast water was given for thirst. Cocoa, was also given without milk. The cocoa 
was made with rice water, in the following proportions: — 

1$. Cocoa 1 drachm 

Rice water 8 ounces 

Sugar 1 drachm 

Scald about five minutes. 



SUBACUTE MILK INFECTION. 311 

A large dose of castor-oil followed by a 2-grain dose of tannopine every two 
hours \\;is given. A high saline injection, 1 quart, temperature 115° F., was ordered 
to cleanse the rectum and colon; also for its stimulating effect. 

The diagnosis of subacute milk infection, congenital syphilis, and furunculosis 
was made. The ease recovered. 

Prognosis and Complications. — This depends on the condition of the 
child. If there is a complication such as nephritis present then the prog- 
nosis is worse than if uncomplicated. If an infant can be removed to the 
seashore from unsanitary surroundings and proper food given, the prog- 
nosis is good. 

Treatment. — Two points to be considered in this condition are: First, 
stop all milk for at least one week and give the stomach and bowels absolute 
rest. Second, cleanse the stomach and bowels of all offending debris which 
may have caused this trouble. Such cases should be put on a light nutri- 
tious diet. 

The golden rule is to give the stomach and bowels absolute rest in both 
quality and quantity of food. The feeding interval should be longer and 
the amount of food reduced. 

In substituting other forms of feeding, pro tempore, we invariably do 
so at the expense of body weight. It will always be noted that children 
deprived of milk will lose weight unless care is taken to substitute a proper 
nutritious food. The body will lose to such an extent that atrophy may 
frequently follow. 

Formula for Weak Infants in Substitute Feeding. — When vomiting and diar- 
rhoea persist give either: — 

Barley water 4 ounces 

Rice water 4 ounces 

Oatmeal water 4 ounces 

Or: — 

Whey 4 ounces 

Feed every two or three hours. Add l / 2 of yolk of egg to each feeding. 

Sweeten with granulated sugar half-teaspoonful to each bottle. If 
■^■•.•mentation exists — colic, greenish stools, and eructations — use saccha- 
rine, i/o grain, instead of sugar for sweetening. 

The liquid culture of lactic acid bacillus, or the lactic acid tablets have 
served me very well in acute entero-colitis, and especially to control fermen- 
tation and colic caused by intestinal toxic bacteria. The liquid culture in 
drachm doses, repeated every three or four hours is non-toxic'. Lactic acid 
tablets, one or two, may be given several times a day regardless of the age 
of the child. 



312 DISEASES OF THE INTESTINES. 

Medicinal Treatment.— A dose of castor-oil should be given at the 
beginning of the treatment, first to cleanse the gastro-intestinal tract, and 
secondly, for its constipating after-effect. Bhubarb and soda mixture in 
doses of one-half teaspoonful are valuable after the castor-oil has been given. 
The treatment described in the chapter on "Acute Milk Infection" should 
be carried out as well in this condition. The successful outcome of the 
case depends on proper rest, careful stimulation, and a thorough cleansing, 
aided by a decided change of air, to the seashore or to the mountains. Milk 
should not be given until all conditions appear normal. Essence of caroid 
in teaspoonful doses, every three hours, is serviceable. Powdered caroid 
combined with charcoal, in doses of 3 grains each, repeated several times a 
day, is very valuable. 

Carbolic acid is extolled by some physicians with large experience in 
infantile diseases. S. Henry Dessau strongly advises a 1 per cent, solution 
of carbolic acid as an intestinal corrective when fermentation exists. He 
has not seen any toxic symptoms from its use. I can fully indorse his 
statement and usually advise watching the urine during the administration 
of carbolized water. A teaspoonful of a 1 per cent, solution, sweetened 
with saccharine, can be given three or more times a day. If no effect is 
noticed in twenty-four hours then 1 1 / 2 or 2 teaspoonfuls can be given at 
each dose. I have also used creosote water, 1 per cent, solution, in the same 
doses as carbolized watur with excellent results. 1 

Appendicitis. 

Appendicitis is an inflammatory condition in and about the vermiform 
appendix. Clinical experience has proven that inflammatory conditions 
in the right iliac fossa originate in the vermiform appendix. 

Bacteriology. — The result of bacteriological investigations of appen- 
dicitis is far from satisfactory. The study of these cases simply empha- 
sizes the fact that the presence of the streptococcus is usually attended 
with symptoms of the severest type. There is a great variability in the 
streptococci found here as well as in other inflammations. They may cause 
but slight disturbance, but are far more liable to result in general peri- 
tonitis or septicaemia. It must be borne in mind that in cases of perfora- 
tion and abscess formation the absence from cultures of pyogenic cocci is- 
of negative value. The pure culture of the bacillus coli communis has 
frequently been found alone, and also associated with the streptococcus pyo- 
genes. Klecki 2 found that pathogenic bacteria of a most virulent type can 
penetrate the peritoneal cavity. This penetration is either during perfo- 
ration or through the lymph spaces of the damaged intestinal walls. 



1 See chapter on "Acute Milk Poisoning" for general treatment of Summer 
Diarrhoea. 

2 Annates de lTnstitute Pasteur, vol. lix, p. 710. 



APPENDICITIS. 



313 



Pathology. — For the purpose of pathological differentiation it is better 
to divide this affection into: First, catarrhal; second, ulcerative; third, 
gangrenous. 

Catarrhal Appendicitis. — In this form the walls of the appendix are 
found thickened and hyperamiic. The lumen of the tube is filled with 
debris of inflammation. If this inflamed condition continues the canal 
may become obliterated. The catarrhal stage frequently ends in resolution. 

Ulcerative Appendicitis. — In this condition the process involves the 
muscular coat because the mucous and submucous tissues have been de- 
stroyed. The ulcer frequently terminates in perforation. 

Gangrenous Appendicitis. — In this condition, also known as intestinal 
appendicitis, rapid necrosis of all the coats of the intestine takes p^ce. If 
a faecal concretion exists and the ulcer perforates, an infection of the peri- 
toneal cavity takes place from the virulent bacteria. Partial or entire 
necrosis sometimes takes place, resulting in sloughing of the appendix. 

Suppuration frequently follows the serous exudation and a localized 
abscess is formed. The danger of such an abscess consists in the perfora- 
tion taking place and the escape of the pus into the peritoneal cavity, 
setting up a diffuse peritonitis. 

Causes. — The etiological factor in appendicitis is hard to define. We 
may have anatomical peculiarities of structure. In some instances con- 
tinued constipation. In others the opposite condition; intestinal catarrh 
and diarrhoea have been thought to be the exciting causes of a given case 
of appendicitis. Irritation from toxic (faecal) accumulations invite, rather 
than cause, this disease. Gouty families in which gall-stones or gravel in 
the kidney have been found, are predisposed to this affection. The name 
of appendicular litliiasis has been given to this form of appendicitis by 
Koux. 

Injuries to this region, exposure to extreme cold and overindulgence 
in purgatives have been looked upon as causative factors. Whether foreign 
bodies, such as seeds or hair swallowed by mouth, will lodge in the appendix 
and cause this disease, is doubted by many. 

Symptoms and Diagnosis. — In general practice we deal with two forms 
of appendicitis. The mild type commonly called catarrhal, and the severer 
form, the so-called perforative appendicitis. 

Mild Form. — In this form the symptoms are so trivial that they fre- 
quently escape notice. Pain, localized, or as it frequently happens diffused 
over the whole abdomen, is complained of. It will, however, be noticed 
that the pain radiates toward a focus which is in the right iliac fossa. This 
tenderness corresponds to a point near the outer edge of the right rectus 
abdominus muscle. If a line is drawn from the umbilicus to the anterior 
superior spine of the right ileum, this point will be in the center and is 
designated as McBurney's point. There is usually a tympanitic percussion 



314 DISEASES OF THE INTESTINES. 

sound, and a circumscribed area of swelling can be felt. The tumor is 
usually of an oval shape and is about two inches or less in length. 

In very young children the attack is ushered in with convulsions, 
whereas older children frequently have chills. Icterus, with deep pigmen- 
tation of the skin and of the conjunctival mucous membrane, may occur, 
but rarely. There is frequently such distinct retention of urine and pain 
in the bladder and external genitals, that we may be misled from the 
actual seat of the disease. In order to relieve the pain the child will 
usually lie on its back with, the right leg drawn up to relax the abdominal 
muscles. 

Fever. — The temperature rises very rapidly. In severe cases it is not 
unusual to find it has reached 105° F. on the first day. In milder forms 
of this disease the temperature will rise to 102° F., or less, on the first day. 
The temperature must not be looked upon as a guide. Not infrequently do 
we find fatal cases in which a normal temperature or even a subnormal tem- 
perature continued throughout the attack. Continued high fever means 
suppuration. A sudden drop to normal signifies either a resolution or 
more frequently a perforation. 

The Pulse. — The pulse should be the guide in appendicular inflam- 
matory conditions. While the same is usually accelerated, a sudden increase 
in the pulse-rate should be noted with suspicion. The toxcemic process can 
therefore best be studied by noting the character and frequency of the pulse. 

Vomiting is an early symptom and one that occasions considerable 
discomfort. In mild forms of the disease vomiting gradually subsides. 
When peritonitis complicates, then vomiting usually recurs. 

The Bowels. — It is difficult to say whether constipation or diarrhoea 
accompanies these attacks. I have seen several cases in which diarrhoea 
continued throughout the whole attack, so that my suspicion concern- 
ing typhoid continued until the localized area of inflammation formed. 
Frequently the symptoms of typhoid fever are so well marked that it is 
well to note the characteristic Widal reaction in differentiating appen- 
dicitis. On the other hand I have seen constipation continue until con- 
valescence was established. 

The appetite is usually poor. The tongue coated with a whitish fur. 
Accompanying the fever there is usually thirst. Pains in the right thigh of 
a neuralgic character are frequently complained of. If a child has fever 
and pains resembling colic, especially on the right side, suspect appendicitis. 

Differential Diagnosis. — The diagnosis is usually not very difficult. 
A sudden pain localized in the right iliac fossa, associated with gastric or 
intestinal symptoms and fever, should render the diagnosis easy. I rely 
upon the examination of the blood as an important guide in determining 
the presence of pus in the system. See article and illustrations of blood, 
showing the reaction, in the chapter on "Blood." 



APPENDICITIS. 315 

We must Dot mistake appendicitis for an abscess in the right ovary. 
The same ran be differentiated by a careful vaginal examination. Jn young 
girls where this is very difficult, an examination can be made with greater 
ease in the rectum. By means of bimanual palpation we can usually differ- 
entiate the same. Acute intestinal obstruction occurs frequently in young 
children. "When the obstruction is due to an intussusception, bloody dis- 
charges from the bowels are generally present. In intussusception the tumor 
is found either in the median line or in the left side, whereas in appendicitis 
it occupies the right iliac fossa. When there is a strangulated gut due to a 
volvulus the pain is not localized. In this form of obstruction of the bowel 
there is usually stercoraceous vomiting. 

Hip-joint disease and tuberculosis might possibly be mistaken for 
appendicitis. There are a great many cases in which a diagnosis will only 
be positive after the abdomen has been opened. 

J. M., 17 years old, was referred to me with the following history: She was 
wet-nursed in infancy and suffered with constipation. When 4 years old had pneu- 
monia; also scarlet fever and measles. When 8 years old had diphtheria, otitis, 
measles, chicken-pox, and mumps. 

For two years she has suffered with violent cramps in the stomach, pain in the 
back, and pain mostly in the right side in the region of the liver. These pains last 
from three to four days; they recur every three or four weeks, and simulate cramps 
in the stomach. Vomiting is frequently associated with these attacks. There is 
usually a temperature ranging between 101° and 103° F. Severe headache and con- 
stipation always accompany these attacks. The menstrual function is prefectly 
normal and independent of such attacks. From the nature of the attacks and the 
location of the pains an attending physician diagnosed gall-stones and biliary colic. 
There seemed to be some tenderness in the ileocecal region. The case was referred 
by me to Dr. William T. Bull with a diagnosis of probable appendicitis. The opera- 
tion was performed by Dr. Bull, and a very long, curved appendix was found, which 
evidently accounted for the symptoms. The gall-bladder was explored and found in 
a normal condition. 

The diagnosis of appendicitis was positive. The girl made a brilliant recovery 
and was observed by me for many months. All cramps and pains have subsided, and 
she is entirely cured. 

This case illustrates the striking similarity of symptoms pointing to 
biliary colic. The rarity of biliary colic in children must be considered 
before a positive diagnosis is made. 

Course and Prognosis. — The prognosis depends on the time when treat- 
ment is commenced. A mild case of appendicitis may resemble colic with 
a 4 slight rise of temperature and pass off unnoticed. If these attacks recur 
our suspicion should be aronsed and the appendix removed. It is a good 
plan for the physician to call the surgeon in consultation when symptoms 
point to appendicitis. Very young infants do not bear laparotomy well, 
owing to the shock caused thereby, but if the surgeon operates rapidly 
shock is greatly lessened. Cases of appendicitis frequently assume a chronic 



316 DISEASES OF THE INTESTINES, 

course. Attacks may recur at intervals of weeks or months. If the diag- 
nosis is positive, it is much wiser to operate during the intervals of health 
rather than run the risk of a fatal complication such as peritonitis. 

Treatment. — First and foremost, absolute rest in bed. The choice 
between hot-water bags and ice-bags depends on individual experience. 
In my own practice I have always favored hot fomentations. The appli- 
cation of several leeches in the early stage of the disease will sometimes 
prove beneficial. It is of importance to see that the bowels have an evacua- 
tion once or twice in each twenty-four hours. If vomiting persists cracked 
ice and champagne may be given. The value of opium is disputed by many. 
It certainly relieves pain, but prevents peristalsis. My choice has been 
codeine, 1 / 10 grain, increased to 1 2 grain, repeated every hour, depending 
on the age of the child, until the pain was relieved. 

If the symptoms continue in spite of the above treatment, it is pos- 
sible that medical treatment is insufficient. Xo time should be lost, but 
prompt surgical relief should be given. 

When Shall We Operate? — A very important aid in diagnosis and 
in deciding the proper time to operate and one frequently overlooked, is 
the blood examination 1 in this condition. 

In appendicitis we have a leucocytosis, while in uncomplicated intus- 
susception and typhoid fever, especially in the latter, leucocytosis is absent 
and leucopenia present. It is easy to see the value of this differential 
method. 

Xow as to its value in deciding the proper time to operate : — 

Leucocytosis means pus — abscess. 

Leucocytosis stationary, that abscess is walled off. 

Leucocytosis increasing, spreading abscess. 

Leucocytosis declining, favorable course. 

From which we conclude that a steadily increasing leucocytosis is a 
bad sign — operate; while a steadily decreasing leucocytosis is a good sign — 
don't operate. 

If a general peritonitis is present operative interference must not be 
delayed. It is in this class of cases that we find a general septic process 
and in which, in addition to the local manifestations, we have a general 
systemic infection. 

Pseudo-appendicitis. 

In atony of the bowel we frequently have impacted f feces. In such 
cases I have known constipation to cause colicky pains and sudden cramps. 
so that the children would cry out suddenly. Eelief was quickly afforded 
by a high soapsuds enema which brought away the offending masses of 
hardened faeces.. Fever is frequently an accompaniment of constipation. 

i Read also polynuclear percentage in chapter on Blood Examination. 



PSEUDO-APPENDICITIS. 317 

It is therefore an important matter to exclude all other factors before 
resorting to extreme measures and advising an appendectomy. The fol- 
lowing two cases were reported by me in Pediatrics, Vol. XIII, Xo. 1, 

190-2 :— 

Case I. — Maggie W., 10 years old, was perfectly healthy until the time of her 
present illness. She was suddenly attacked with pain, which was localized in the right 
hypochondriac region; the pain was very acute and was increased on pressure; the 
abdomen was distended and quite tympanitic on percussion; there was a marked 
dullness in the ileocecal region; there was an intense vomiting, the vomit containing 
particles of food along with mucus and bile and had a very offensive odor. The 
child vomited several times in one hour and seemed to vomit whenever the pain was 
most acute. The mother stated that the child had a regular movement of the bowels 
once in twenty-four hours, that she had had a movement that day and that her 
appetite had been quite good. She was a very strong and well-nourished child with 
no evidence of organic disease ; there was no hysterical element ; the child complained 
of no other pain but that directed to this abdominal condition ; there was a history 
of improper diet but no history of traumatism; the heart-sounds were normal; no 
murmurs were audible, the lungs were normal on percussion and auscultation; the 
liver did not seem to be enlarged; the spleen was palpable but not enlarged; the 
temperature was 104° F., taken in the rectum; pulse, 110; respiration, 20. 

When first seen an ice-bag had been applied over the most tender spot in the 
abdomen. Codeine in V 6 -grain doses had been administered and a liquid diet pre- 
scribed. The child was first seen by me about twenty hours after the commencement 
of her illness with the above-named conditions. As this case had been seen by 
another colleague I was requested to meet him in consultation. The diagnosis of 
perityphlitic abscess had been made and an operation advised. The diagnosis was 
not so positive owing to the history of overeating. The child partook of many 
kinds of cake and pastries while celebrating a birthday, and an overloaded stomach 
appeared most plausible. Hence an acute catarrhal gastritis was diagnosed. The 
pain and tenderness in the abdomen was ascribed to a colicky condition, resulting 
from fermentative processes in the stomach and extending into the intestine. The 
indication was to cleanse the stomach and bowels as rapidly as possible and thus 
remove the toxaemic condition which existed. Meanwhile an operation was not con- 
sidered until after the above measures were used. 

The urine was examined and showed a large excess Of phosphates; no albumin, 
no sugar, no casts, no diazo-reaction ; "hence we excluded typhoid. There was a very 
strong indican reaction and this latter strengthened the diagnosis of fermentation 
due to intestinal putrefaction. 

The Treatment. — I suggested the use of a very high enema with a long tube 
reaching into the colon; the enema consisting of 1 pint of glycerine diluted with 2 
pints of warm water; the temperature of the same was 102° F. The enema was 
very effectual and brought away a large amount of gas. The temperature which, 
as above stated, was 104° F., fell to 102° F. within one hour and gradually returned 
to normal in twelve hours, although no other antipyretic measure was used. Small 
doses of citrate of magnesia were ordered, a tablespoonful hourly, to quench thirst 
and at the same time to have a slight laxative effect. A liquid diet was continued, 
and thirty-six hours after the above remedies were ordered the child was in a 
normal condition. 

Case II. — A female child, about 10 years old, was seen by me through the 
courtesy of Dr. L. Harris, with severe abdominal symptoms. The most prominent 



SJs DISEASES OF THE INTESTINES. 

symptom was an intense pain localized in the right hypochondriac region, more espe- 
cially in the ileocecal region. There was a marked distention of the whole abdomen; 
there was constipation and vomiting: the temperature ranged between 102' and 
103° F. ; the pulse, which was 110. rose to 120. The child complained of an intense 
headache; in the beginning she also had a chill. The history, as given to me by 
Dr. Harris, was that the child had fallen from a fence on which she was standing, in 
the yard, a distance of about three feet. He believed that she had injured herself. 
The doctor's diagnosis was peritonitis from traumatism. In this diagnosis I con- 
curred. There was no distinct localized area of pain, but rather a diffused area of 
pain extending over the whole of the abdomen, which was intensified in the immediate 
locality of the injury. There were no chills: there were no rigors; the tempera- 
ture rose gradually: there was no evidence of suppuration and none suspected. 
The child was placed on a carefully restricted liquid diet, consisting of broth, soup, 
strained gruel, milk, egg albumin in various forms and in addition thereto opium in 
the form of deodorized tincture was given to alleviate pain. Attention was directed 
to the bowel and an enema, was given to flush the rectum and colon and relieve 
accumulated faeces. 

Another colleague saw the child and diagnosed appendicitis, and suggested 
immediate operative treatment. I was again requested by the attending physician. 
Dr. Harris, to meet with this other colleague, and as a result, we decided not to 
have operative interference until we were satisfied that we were dealing with a puru- 
lent case. Palliative measures were used, such as ice. locally. In addition thereto 
the most absolute rest was enjoined, and the child made a brilliant recovery without 
an operation. We were satisfied that we were dealing with a traumatic peritonitis 
in which the local area of pain was due to the traumatism. 

A careful review of the above two cases will show that when the diag- 
nosis of appendicitis is made by a process of exclusion then greater care 
should be exercised before resorting to extreme measures. 

In the first case the high temperature and the suddenness of the 
attack certainly showed marked symptoms pointing toward appendicitis. 
The high temperature was due to the toxaemic condition resulting from 
impacted faeces. The pain was an enteralgia due to a distended gut filled 
with gas. Such colicky conditions are so frequent in young infants that 
we could operate very frequently if the diagnosis of appendicitis were made 
every time an infant screams with pain. The cases above reported are very 
interesting as showing that cases will frequently have symptoms resembling 
perityphlitis or perityphlitic abscess, so that a differential diagnosis will be 
very hard to make. Xot infrequently cases of appendicitis will be over- 
looked, and when such is the case, if they are of the catarrhal type, no 
harm will ensue therefrom. On the other hand, I must not be understood 
as disparaging the idea that no case of appendicitis requires an operation, 
but my object in calling attention to these two cases is to offer a plea that 
before a case of supposed appendicitis is subjected to an operation, that we 
should be sure that all other conditions, such as impacted faeces, as in my 
first case, and other allied conditions have been excluded in the diaornosis. 



INTUSSUSi EPT1( >N. 319 

Auto-intoxication. 

In very young infants auto-intoxication of the intestines is caused by 
proteid or fatty in _ - n and fermentation, and is one of the most fre- 
quent causes of high fever. 

Too frequent feeding, or the feeding of food containing a high fat or 

ssive proteid suitable for the infant, provokes dyspeptic indigestion. 
From this indigestion we have fever and the products of decomposition 
resulting in toxaemia. If this toxaemia continues convulsions frequently 
follow. 

Another common form of auto-intoxication met with is due to stagnant 

-. An impacted stool, especially if atony of the intestine exists will 
frequently cans s temperature and give marked systemic disturb- 

- such as loss of appetite and headache. The abdomen is distended, 
notably the transverse colon. The urine is high colored and gives an 
indican reaction. 

The treatment consists in relieving the bowels by an injection of one 
pint of soap water. Internally 5 grains of compound jalap powder with 2 
grains of calomel should be given. Milk should .be stopped. Whey or 
thin broths should be given for at least twenty-four hours. Water liberally 
is required. 

Ixtussusceptiox. 

The most frequent form of obstruction of the bowel is that known as 
intussusception, or invagination of the bowel. 

Intussusception involves three layers of the bowel, each layer coi - - - 
ing of all the intestinal coats: First, the outer layer is kno^n as the intus- 
suseipiens, the sheath or receiving layer: second, the internal is known 
as the entering layer which, together with the third, the middle or return- 
ing layer, constitutes the invaginated part known as the intussusceptum. 

The clinical records show that about one-half of all cases occur at the 
junction of the small and large intestine. 

When the ileum becomes invaginated in the colon, the condition 
is termed ileo-colic intussusception. 

In less than one-third of all cases invagination takes place in the small 
intestine. This is known as ileal or jejunal intussusception. When this 
invagination takes place only in the large intestine it is called colic intus- 
susception. 

This usually commences at the ileo-csecal valve and extends down- 
ward. It is felt as a tumor much larger than the swelling found in appen- 
dicitis. 

Intussusception usually causes a recession of the abdomen from the 
gid of the ccecum, while appendicitis, if it does anything, will at 
prevent recession of the abdominal walls at this point. 



320 DISEASES OF THE IXTESTIXES. 

Symptoms and Diagnosis. — Nausea and vomiting are among the 
earliest symptoms. Later in the disease the vomit becomes faecal (so-called 
stercoraceous vomit) in character. The child has pain; assumes the dorsal 
position with the thighs drawn up on the abdomen. The pain appears in 
paroxysms accompanied with a discharge of blood and mucus. Eectal 
tenesmus also is present. The temperature ranges between 101° and 103° F. 
The pulse from 120 to 150 per minute. 

Cases that give a clear history of intestinal obstruction with no stool 
passing, and vomiting caused by such obstruction, offer a good prognosis if 
operated early. Continued vomiting of food will cause exhaustion and rob 
the infant of the vitality necessary to undergo the shock caused by the 
operation. 

The following case will illustrate intussusception as met with in gen- 
eral practice. The history was as follows : — 

Infant B., five months old, had vomited for some time; was constipated, having 
had no stool for several days. The temperature was about normal ; the abdomen 
was distended. Antiperistaltic movements of the stomach were noticed. The child 
was breast-fed. The breast was discontinued for a short time and barley water sub- 
stituted to relieve the vomiting. 



STOMACH. ^ , ANUS. 



Fig. 88. — Mechanism of Intussusception (Treves). The sheath at A 
passes to B, then to C. The lower part of the intestine is drawn over the 
upper instead of the upper crowded into the lower. For a fuller description 
see Treves' s "Intestinal Obstruction," London, 1884. 

The family was alarmed and sent for Dr. A. E. Isaacs, of this city, through 
whose courtesy I saw the child several times in consultation. 

The vomiting continued in spite of the withdrawal of the breast-milk. 
Paroxysms of pain constantly recurring. Infant screaming. Repeated enemas 
did not result in emptying the bowels. Calomel had been given in both 
large and small doses with no satisfactory result. In addition thereto 
cathartics had been given, and this did not produce a cathartic effect. As 
the vomiting persisted, we believed that lavage would be of some benefit. The 
stomach was carefully washed with the aid of a Xelaton catheter. The cleansing 
solution was 1 quart of normal salt solution. The gastric contents were syphoned 
off until the return flow was clear. The stomach was then given rest for half a 
dozen hours and the breast-milk was again tried. The vomiting persisted, at the 
same time the distention in the abdomen continued. The diagnosis intussusception 
was made and an operation suggested. The family objected to the operation and 
palliative measures were used. The nurse was able to pass about fourteen inches of 
catheter into the gut until she reached the obstruction. We had hoped that probably 
a slough would relieve this strangulated gut. Later in the disease Dr. Isaacs was 
able to feel the mass of gut in the rectum about two and one-half inches from the 
anus, and to pass a catheter outside of the intussusception, as well as inside of it, 
some fourteen inches without reaching the limit of the invagination. The child was 






IN ll SSI SCEPTION. 321 

seen by me at three differenl times. The symptoms which were aiost marked in 
this case were : — 

1. Continued vomiting. 

2. Faecal impaction, the gut being so obstructed that no faeces passed in more 
than ten day-, though flatus would occasionally pass. 

3. During the first two or three days not only was clear blood passed per 
rectum, but large masses of jelly-like mucus tinged with blood were frequently 
expelled from the rectum until the end. 

4. The distended belly, the abdomen abnormally distended, and very tympanitic 
on percussion. 

5. The absence of all inflammatory symptoms such as rise of temperature until 
two days before the death of the patient, when the temperature rose to 101° F. and 
the pulse rose to 160. (See Fig. 89.) 

0. Continued crying; the child with rare exceptions showed evidences of pain. 
There was no positive etiological factor in this case, as there were two other 

healthy children in this family; the father and mother were in apparent good 
health. There was no evidence of traumatism nor anything that could be connected 
with the cause of this condition. The mother stated that for a period of two months 
before the appearance of this condition she had given a patent cathartic every day, 
as she thought,, with advantage. Whether, or no this drug had anything to do with 
this condition it is difficult to state. The presumption is, however, that the con- 
tinued effect of giving cathartics was indirectly the cause. 

In the above-reported ease an operation was refused and the child 
died. The chances were in its favor : — 

1. Because it was a well-developed and well-nourished baby. 

2. Because it was breast-fed. 

3. Because the diagnosis was made very early in the disease. 

T. Because the heart's action was very good, and no chronic or infec- 
tious disease existed. 

In 1ST0 Pilz 1 reported 91 cases under 1 year — mortality, 81 per cent. 
From 18T0 to 1891 135 cases, under 1 year, gave mortality of 59 per cent. 

The reduction in percentage of mortality in recent years is evidently 
due to modern aseptic surgery. Whereas formerly recovery depended on 
sloughing, to-day laparotomy is the rule. 

Two interesting clinical points which I have made use of are given by 
Cattle :— 

1. Try to reduce the obstruction by non-operative means — injections 
of oil — the child in an inverted position following the injection ; gentle 
manipulation of the abdomen. 

2. In percussing the abdomen there will generally be found at the 
site of the obstruction a very tympanitic area adjoining a dull area. By 
carefully noting this point the surgeon has an important landmark for his 
guidance in performing the operation. 

Prognosis. — Without operation the prognosis is exceedingly bad. The 
earlier the operation, the better the result. In some cases Xature relieves 



Jahrbuch ftir Kinderheilkunde. Bd. iii, p. 6. 

21 



322 DISEASES OF THE INTESTINES. 

the invagination and a slough will separate. This is, however, a rare con- 
dition. 

Treatment. — When the diagnosis is established no time should be lost. 
Inflation of the towel with air or hydrogen gas through a long rubber tube 
has been recommended. When this is not successful the child may be in- 
verted and gentle manipulation of the abdomen may be attempted. 

Injections may be given with or without anaesthesia. The baby is 
turned on its belly, the hips are raised by gently supporting the abdomen 
on a soft pillow. The mouth and nose, being the lowest part of the body, 
must be protected. The baby is then anaesthetized with chloroform, and 
warm water is poured into the rectum with but little pressure, from a 
height not exceeding three feet. The injection is frequently intermitted, 
while the anus is closed with a cotton plug held by the finger. At the 
same time the abdomen, in the direction from below upward, is gently 
kneaded and its contents moved about. 

Unless this proves successful no time should be lost and an abdominal 
operation should be performed. 

Although surgical interference offers the best means of treatment, we 
should note the condition of the child at the time of operation, and con- 
sider the result of shock and haemorrhage in estimating the therapeutic 
result. No cathartics should be given after the operation, but the bowels 
should be confined by administering a small dose of opium. Stimulation 
will be urgently demanded, hence whisky or iced champagne should 
be given ab libitum. It is well to remember that very young children do 
not offer good resistance to the shock of an abdominal section. Fully 50 
per cent, of cases seen by me were fatal. The details of an operation for 
intussusception are those of aseptic surgery, for which my readers are 
referred to the special books on surgery. Dr. John F. Erdman, of New 
York City, has reported a series of successful operations in very young 
children. 

Umbilical Hernia. 1 

This condition is frequently seen in both male and female children. 
It is more often seen in the female. 

Causes. — It is usually found in children with flabby muscles such as 
rachitic and atrophied cases. Severe abdominal strain during the parox- 
ysms of whooping-cough or in continued constipation, frequently results 
in umbilical hernia. The tumor may be from one-half to one inch wide, 
and the same also in length. 

Treatment. — Preventative Treatment: After the umbilical cord has 
separated, the usual flannel binder may be used to lend support to the 
abdomen for the first two or three months. 



1 For Inguinal Hernia, see chapter on "Diseases of the Genito-Urinary Tract.' 



TATKWORM. 



323 



Mechanical Treatment. — A pad of absorbent cotton into which a thick 
piece of cork or a wooden button the size of a 25-cent-piece is wrapped, 





Fig. 90. — Umbilical Hernia. The result of violent paroxysms of 
whooping-cough. (Original.) 

should be snugly pressed over the protruding part and secured by thick 
straps of zinc oxide plaster. This dressing should be renewed every four 

• or five days. The treatment must be 
continued for several months. 
31 A truss, consisting of a rubber 

pad and a belt to pass around the 
SgggBJ body, should be applied, so that it 
cannot slip and has enough pressure 
Fig. 91.— Umbilical Hernia Truss. to keep the hernia in place. 

Tapeworm (Cestodes). 

The tapeworm enters the body by food containing the larvae. Sev- 
eral varieties are met with. When the worm is fully developed it consists 
of rectangular segments or pieces. These segments are also called pro- 
glottides. The head and neck of the worm are called scolex. 

The eggs (larvae) of the taenia solium are found in pork; taenia 
mediocanellata, in beef; bothriocephalus latus, in fish; taenia cucumerina, 
in dogs and cats. 



324 DISEASES OF THE INTESTINES. 

Development of the Worm. — A worm develops in about three months. 
When the terminal segments are mature they separate and are discharged 
in the stool. As each segment contains both male and female organs, each 
one is capable of regenerating a whole worm. For this very reason the 
treatment of a tapeworm will never be successful until the head and every 
segment has been expelled. Tapeworms are estimated to live from ten to 
twenty, and possibly, thirty years. 

The beef tapeworm is the most frequent found in children. It has 
four suckers, a square head, and no hooks. Eaw meat may contain the 
cysticerci. 

The pork tapeworm is the rarest found in children. The head has 
four suckers, surrounding which there is a circle of about twenty-six hooks. 
The length of the worm varies from ten to fifty feet. Nursing children 
are exempt from tapeworm. 

Symptoms. — In children between 2 and 4 years of age subjective 
symptoms are difficult to interpret. In older children we will notice 
attacks simulating colic associated with fairly good movements of the 
bowels. There is restlessness at night and marked nervous irritab'lity by 
day. The breath is foul and the child presents evidences of marked 
anaemia. In spite of an abnormally large appetite the body wastes and 
the child is believed to suffer with some latent form of tuberculosis. 

Diagnosis. — The diagnosis is positive only when segments of the worm 
are found. The absence of cough or pulmonary symptoms will usually aid 
in excluding tuberculosis. At times several weeks will pass before a posi- 
tive diagnosis can be made. 

Prognosis. — The prognosis is usually good. It is simply necessary to 
use radical treatment to dislodge and sicken the worm and then expel it. 

Treatment. — The taenicide should be given after fasting and followed 
in an hour by a cathartic to carry off the worm. The best tamicides are 
pomegranate or its alkaloid, pelletierine; filix mas; kousso; pumpkin- 
seed; turpentine, and cocoanut. 

R Oleo resinae aspidii 1 fluidrachm 

Tinct. quillaise 1 / 2 fluidrachm 

Tinct. aurantii dulcis 1 fluidrachm 

Syr. aurantii, q. s. ad 7 fluid ounces 

M. Sig.: A teaspoonful for a child 5 years old (C. W. Townsend). 

R. Tannate of pelletierine 1 / 2 grain 

Sig.: For a child 3 to 5 years old (T. M. Rotch). 

I£ Olei terebinthinse 1 fluidrachm 

Olei ricini Va ounce 

M. Sig.: Take it in one dose (Farqhuarson). 



PLATE XI 




Cestodes 'Tape-worm- . 1. Taenia saginata. A. Head of taenia sagi- 
nata. 2, Dorsal view of the head. 3, Apex view of head, showing depres- 
sion in center. ./. Isolated, elongated segments. ■'. Bothriocephalic latus. 
6. Eipe segment- of taenia saginata. B. showing location of sexual organs. 
7, Half-developed segments of taenia saginata. Illustrations drawn from 
specimens. (Original.) 



\m \i;is LUMBRK OIDES. 325 

Since entire expulsion of the tapeworm is effected with difficulty, 
preparatory treatment for about forty-eight hours should be employed 
before the vermifuge is administered. During this time the patient should 
take a mild purgative once or twice, and such food in moderate quantity 
should be allowed as leaves little residuum, as beef-tea, etc., with some 
stimulant if the patient feels exhausted. There are three articles of food 
which experience has shown to be especially useful in this preparatory 
treatment, perhaps from a sickening effect which they produce upon 
the worm, namely, salt herrings, onions, and garlic. This may, therefore, 
be taken as food in the twelve or eighteen hours preceding the employment 
of the vermifuge, which it is ordinarily most convenient to administer in 
the morning. (J. Lewis Smith.) 

ASCARIS LUMBRICOIDES (KOUND WORM). 

This worm is a reddish or yellowish round worm, usually from 5 to 
10 inches long. The male worm is smaller than the female. This worm 
inhabits the small intestines. It is seldom found solitary, but usually 4 
to 10 may be present. Some authors state that as many as 200 and 300 
have been found at one time. The worm is usually found in children be- 
tween the second and tenth years. It is never found in nurslings. These 
worms will wander from the small intestines into the stomach and irritate 
the gastric mucosa. They are frequently expelled by vomiting. 

A child 4 years old was seen by me during my service at the Willard Parker 
Hospital in the fall of 1903. The child had pharyngeal and tonsillar diphtheria. It 
was a septic type of diphtheria. The child vomited a round worm about 6 indies 
long on the second day after admission. On the third day another worm about 5 
inches long was also ejected by vomiting. There were no symptoms pointing to the 
presence of these round worms. 

Some authors report worms wandering into the nose and also into 
the middle ear. A worm entering the larynx has produced fatal asphyxia. 
Another author reports jaundice due to worms entering the common bile 
duct. Worms have been known to produce hepatic abscesses. They have 
been found in the vermiform appendix. These worms appear most fre- 
quently in the stools. They have been found in umbilical abscesses. 

Symptoms. — Very indefinite symptoms can be ascribed to these round 
worms. Irritation, such as restlessness at night, grinding of teeth, picking 
the nose, and scratching the anus. Abdominal symptoms, such as colic, 
diarrhoea, and tympanites are frequent. This clinical picture must not 
be presumed to be present in all cases. Not infrequently symptoms of 
meningitis will be mistaken for worms. Be sure to exclude all other con- 
ditions before expressing a positive opinion. Nervous symptoms such as 
hysteria, vertigo, and epileptiform convulsions have been noted while 



26 DISEASES OF THE INTESTINES. 



worms existed. As these conditions disappeared when the worms were 
expelled, it is but fair to presume that they were indirectly the cause of 
these nervous manifestations. 

Diagnosis. — A positive diagnosis can only be made if the round worms 
are discharged from the body or if the ova is discovered in the stool. The 
microscopical examination, therefore, is very valuable and should always 
be made when in doubt. If the ova are still found in the stool after one 
or two worms have been expelled, then more worms should be suspected. 

Prognosis. — The prognosis is always good, but the child must be kept 
under constant observation for at least several months. 

Treatment. — To eliminate worms from the body, the taenicide should 
be given for several days and then followed by a brisk cathartic. The fol- 
lowing formulae have served me very well: — 

Ifc Magnesii sulphatis 4 drachms 

Syrupi rubi idsei 2 fluid ounces 

M. Sig. : A tablespoonful two or three times a week, to be preceded by 
santonin, 1 spigelia, or chenopodium. Once a day a high enema of soapy water should 
be given. The folds of the anus should be carefully cleansed with soap and water, 
and the following ointment applied: — 

I£ Acidi boracic 1 drachm 

Olei rosaa 3 drops 

Vaseline 1 ounce 

M. Sig.: Apply externally. 

Other tsenicides recommended by Townsend are : — 

B Ext. spigelise 10 fluid ounces 

Ext. sennae 6 fluid ounces 

Olei anisi 20 minims 

Olei cari 20 minims 

M. Sig.: Half teaspoonful for a child 2 years old, two or three times daily. 
Teaspoonful for a child from 4 to 10 years old. 

Or:— 

B Oil of chenopodium 2 drachms 

Sig.: To be given on sugar three times daily, in doses of 5 drops, to a child of 

3 years. Ten drops to a child of 10 years. A cathartic should be given every 

second or third day. 

Oxyuris Vermicularis: (Pixworm: Threadworm). 

The female worm is thin, yellowish white, and has a pointed tail. 
The male has a strongly curved tail. The male worm is rarely found in 
the stool. The female worm is present in greater number than tlie male. 

1 The formula for santonin is given in the chapter on "Oxyuris Vermicularis." 



WORMS. -527 

The oxyuris is frequently passed in the mucus during a catarrhal discharge 
from the rectum. These worms frequently wander from the rectum into 
the vagina. 

Symptoms. — Irritation and itching of the anus, causing restlessness 
and severe nervous manifestations, usually appear after the child is in a 
warm bed. The itching frequently gives rise to a des're for frequent 
urination. In severe cases it may lead to masturbation. The constant 
scratching to relieve the itching has produced vulvitis and vaginitis. Con- 
vulsions have been brought on by reflex irritation due to the presence 
of worms. 

Treatment. — Threadworms are most effectually and easily removed 
by the use of enemata. For this purpose lime water, or an infusion of 
quassia, or solution of common salt (a teaspoonful of salt to four ounces 
of water), may be employed. In using these agents the bowels should first 
be cleansed by a copious injection of warm water. Jacobi recommends a 
decoction of garlic as an enema in these cases. 

Ifc Santonin 1 to 2 grains 

Mild chloride of mercury 1 / 2 grain 

M. Sig. : Every night for two or three nights, to a child 5 or 6 years old, 
and followed each morning by a purgative dose of castor-oil. 

Or:— 

B Santonin 1 grain 

Compound liquorice powder 2 drachms 

(Eustace Smith.) 



CHAPTEB V. 

DISEASES OF THE RECTUM. 

Fissure of the Anus. 

An ulcer having its long diameter parallel with the long axis of the 
bowel is occasionally met with. It occurs at the anal margin. It is seen 
in infants as well as in older children. It is caused by the passage of 
irritating hard faecal masses. It is also occasionally seen after prolonged 
diarrhoea with continuous straining. Some authors state that traumatism 
from the nozzle of a syringe may cause a fissure. This I have never been 
able to verify. Streaks of blood of a bright red color will usually be seen 
in the stools when a fissure is present. 

The prognosis is good. 

Treatment. — This should be mainly hygienic, and consist in thorough 
cleansing of the parts. The application of solid nitrate of silver will 
usually effect a cure. The bowel should be relieved daily by the injection 
of sweet-oil or glycerine to soften the faeces. Some authors advise stretch- 
ing the sphincter of the anus and keeping the parts at rest. 

Simple Catarrhal Proctitis. 

The rectum is rarely inflamed without additional portions of the 
bowel being involved. When the same exists, local causes must be looked 
for; for example, carelessness while irrigating the rectum. Mistakes, such 
as corroding or caustic drugs, can set up an inflammation. An instance 
of this kind occurred in my practice when a child received a strong injec- 
tion of carbolic acid, causing inflammation. Infection extending from 
the vagina or urethra, such as gonorrhoea or diphtheria, can cause this 
condition. Syphilis has been known to affect the rectum. In simple ca- 
tarrh the pathological lesions are the same as those found higher up in the 
gut. 

The symptoms are pain when the bowels move. The stool contains 
mucus, which may be distinctly separate. When folds of mucous membrane 
protrude they are very angry looking and show a deep red pigmentation. 
Children old enough will complain of intense burning and itching. 

The treatment consists in using bland injections such as oatmeal 
water or starch water: when severe tenesmus exists, bicarbonate of soda, 
a teaspoonful to a pint of water, is beneficial. 
(328) 



[SCHIO RECTAL ABSCESS. 329 



Croupous Proctitis. 

This is the form usually associated with diphtheria of the genitals. 
Large and small pieces of mucous membrane arc found mixed with the 
stool. Pathogenic bacteria, such as the streptococci and staphylococci, are 
found in the dejecta. 

The treatment consists in using bland antiseptic irrigations, bichlo- 
ride of mercury, 1 to 5000, or a normal saline solution, repeated several 
times a day. If diphtheria is present, antitoxin should be given (see 
chapter on f< Antitoxin"). 

If syphilis is present the usual treatment for the same (see chapter 
on "Syphilis") is indicated. 

Ulcerative Proctitis. 

Tuberculous ulceration of the rectum has been reported by Steffen; 
also by Holt. Syphilitic ulcers are rare in children. There is usually 
bleeding and tenesmus. The blood is of a bright red color. The diagnosis 
is easily made by examination with a speculum and by no other means. 

The treatment is very difficult. First, cleanse the rectum. Apply, 
locally, nitrate of silver with the aid of a speculum. The insufflation of 
iodoform, dermatol, or europhen is very practical. 

HAEMORRHOIDS. 

This condition is occasionally met with in children. It usually ac- 
companies chronic constipation. The persistent constipation associated 
with cretinism occasionally causes this condition. 

An instance of this kind was seen by me in a child about 2^ years old, which 
was referred to me because it could neither walk nor talk. It had been operated 
for congenital adenoids by Dr. W. Freudenthal. The case had been under the treat- 
ment of Dr. A. Jacobi for one year. In this case chronic constipation was associated 
with haemorrhoids. The stool was so hard and dry that blood was occasionally 
found after severe tenesmus. Thyroid treatment was directed against the cretinism, 
and malt extract ordered to overcome the constipation. 

The usual treatment consists in removing the cause as much as pos- 
sible as above described. 

I have never met with a case under 12 years of age that required 
operation, although instances of this kind are occasionally described in 
surgical literature. 

ISCHIO-RECTAL ABSCESS. 

In excoriated conditions around the anus, following continued diar- 
rhoea, an infection frequently results from scratching. Pyogenic bac- 
teria undoubtedly enter the lymph channels. 



330 DISEASES OF THE RECTUM. 

A case of this kind was seen by me in the family of Dr. J. Grosner, of New 
York City. An infant nursing at the breast had "dyspeptic symptoms, such as flatu- 
lence, and, later, intestinal catarrh. An ischio-rectal abscess developed later on. It 
was benign and required a simple incision with careful attention to asepsis. This 
condition lasted in all about two weeks. The child made a splendid recovery. 

At times we meet with very deep-seated inflammation which requires 
the skill of the surgeon. When a fistula exists proper surgical treatment is 
indicated. 

Prolapsus Ani. 

When children strain, especially during constipation, prolapse of the 
anus frequently follows. Not infrequently as much as one or two inches 
of the mucous membrane protrudes. (See Fig. 122.) 

Causes. — There are three main causes: First, weakness of the levator 
ani muscles. In general atonic conditions — for example, in rickets — this 
condition frequently follows constipation, the constipation being a part 
of the rickety condition and indirectly causing a straining during defeca- 
tion, thus ending in prolapse of the rectum. Deficient peristalsis, espe- 
cially in young children, induces them to strain to expel hardened faecal 
matter. On the other hand constant diarrhoea and irritation in the lower 
bowel may also result in prolapse. When an attack of summer complaint 
has lasted a long time, we usually find at the end of defecation that the 
rectum protrudes. 

Second, when the ischio-rectal fat is deficient. In marasmic condi- 
tions, such as in athrepsia infantum or following the acute infectious dis- 
eases, when high fever and general wasting have taken place, the body fat 
suffers, and so the mechanical support of the rectum is lost. 

Third, traumatic condition. This condition is frequently induced 
by coughing paroxysms, hence it not infrequently follows whooping-cough. 
Eetention of urine, phimosis, and vesical calculi may cause this condition. 

Diagnosis. — The size and the location of the tumor, and its appear- 
ance during the straining while at stool, render the diagnosis easy. The 
ease with which the prolapse can be replaced is noteworthy in making a 
diagnosis. It is rare for this condition to be mistaken for intussusception 
(see chapter on "Intussusception"). A polypoid growth is usually found 
independent of the straining during defecation. 

Treatment. — Local: Place the child in the knee-chest position and 
apply olive-oil to the prolapsed bowel, after which the gut can be replaced. 
When this mild manner of reduction is not successful, a whiff of chloro- 
form should be used to quiet the child. This will also relax the protruding 
part. After replacing the gut the buttocks should be supported by a stout 
strap of adhesive plaster running from side to side. Cold water irrigations 
should be given. These will have the two-fold object of emptying the 



RECTAL 1'OIATI. 



331 



Lower bowel as well as toning the muscle. Astringent injections of sulphate 
of zinc, 1 grain to the ounce, or tannic acid, 10 grains to the ounce, are 
recommended by some. I have failed to see any benefit therefrom. The 
local application of the tincture of the chloride of iron once every three 
days has seemed to be of some benefit. The solid stick of nitrate of silver 
or cauterization by means of the Paquelin cautery, made red hot, is fre- 
quently recommended. Heroic measures, such as amputation of the parts, 
are rarely, if ever, necessary. 

Constitutional Treatment. — We must not expect to cure a condition 
of this kind unless the body is strengthened. Restoratives, cereals, eggs, 
and milk must be in-escribed. We can supply a deficiency of fat by order- 
ing codliver-oil or lipanin, 1 teaspoonful three times a day. When con- 
stipation exists the addition of malt, as in a malted food, will aid this 
condition. Strychnine may be given in doses of 1 / 100 of a grain, and 
increased gradually until 1 / 60 of a grain is given, three times a day. Iron 
can also be given with great advantage. Massage of the abdomen and 
electricity must not be forgotten. A cold shower or spray over the spine 
and abdomen, repeated every day, is an excellent tonic. 



Rectal Polypi. 

Polypus of the rectum is very common in early life. When bleeding 
occurs it may be due to a fissure or to a hard scybalous stool tearing 
the mucous membrane. It may be caused by a rectal polypus. Frequently 
we find this condition in syphilis. 

The treatment consists in tying off the polypus with fine catgut or 
snipping the polypus with a scissors and then cauterizing the base. 



CHAPTER VI. 

DISORDERS RESULTING FROM IMPROPER NUTRITION. 
( FAULTY METABOLISM ) . 

Faulty Metabolism. 

This condition is primarily due to faulty feeding, or to conditions asso- 
ciated with improper nutrition whereby faulty metabolism results. It is 
found in infancy, but is also very prevalent in older children between the 
ages of 4 and 14 years. We find a subnormal condition of the skin which 
may be cold or moist, or the skin may be found dry, and the circulation 
poor. The extremities are cold; cyanosis is not present. Such children 
frequently have marked vasomotor disturbances manifested by unilateral 
flushes of the face, of one ear, or the nose. The elasticity of the skin is 
much less than normal. Adipose tissue is usually lacking, although this 
type of cases may be unusually fat. Such adiposity is due to faulty assimila- 
tion. The child shows the evidence of defective nutrition. It is underfed. 
If it is not underfed, then the food is not assimilated. Sometimes both 
quantity and quality of food are properly regulated and still subnormal 
conditions prevail. An absence of the internal secretions due to functional 
inactivity of various glands associated with the digestive tract is most 
probable because such cases have, first, 

Lienteric stools in which undigested particles of food may be found. 
Such lienteric condition may be modified by a stimulation of glandular 
activity, such as the salivary and peptic glands. We must not undervalue 
the role played by the pancreatic ferments, and the necessity for that most 
important of all glands, namely, the liver. Inactivity on the part of the 
liver and the absence of a proper secretion of bile are two of the most 
potent factors in causing faulty metabolism. 

Second. Scybalous Stools. — When dry, round, faecal masses stagnate in 
the colon they set up a series of symptoms which yield one of the most 
frequent sources of trouble in children. In this type of stagnation of 
faeces, one of the prime causes is the absence of tone to the intestinal 
muscles, but the dryness a-nd lack of secretion per se is due to the absence 
of proper lubrication from a subnormal mucous membrane. It is plain, 
therefore, that we must seek the origin of this trouble in a deficiency of the 
secretions previously named or in the absence of a proper secretion of bile. 
The bile salts, especially in infancy and childhood, have a most important 
bearing on the efficiency of digestion. Unless the liver performs its func- 
tion, faulty metabolism is inevitable. Whenever possible the urine should be 
examined for the presence of indican. Indicanuria usually accompanies 
(332) 



FAULTY METABOLISM. 333 

stagnation of intestinal contents, and is frequently associated with symptoms 
that make up a clinical picture of autointoxication of the intestine. Fever, 
so-called absorption fever, is usually a bi-product of this stagnation, and the 
temperature will range from H»<>° to 102° F. for many weeks, or until the 
diet is bo reduced and the gastrointestinal tract so cleansed that intestinal 
stagnation is impossible. 

It is readily seen from what has just been said that faulty metabolism 
robs the bones of their proper nutrition, and by a deficient quantity of blood 
the nutrition is subnormal ; hence rickets due to soft bones results. A defi- 
ciency of lime salts in the bones is evident in the teeth, which show carious 
manifestations and a breaking down, so-called chalky teeth. 

What applies to the bones is true also concerning the muscles. The 
muscles are flabby and soft, and show the lack of tone that good healthy 
muscular tissue should show. Such children are very restless at night ; a- a 
rule the general atony of the muscles of the bladder results in enuresis. 

The atony of the intestine is evident in deficient peristalsis and eon- 
sequent eoprostasis. The obstipation if present results from dryness and 
lack of secretion in the intestine ; hence scybalous stools are noted. 

Faulty metabolism is very evident in the nasopharyngeal tract. Such 
children have the adenoid habitus, they are prone to infections, and are 
constant sufferers from tonsillitis and swelling of the adenoid vegetations. 
The cervical glands are usually enlarged. These children are frequently 
victims of bronchitis and pneumonia. 

Owing to this subnormal condition the immunity of the body and the 
phagocytosis are so greatly minimized that such children not only invite all 
exanthematous infections but frequently succumb therefrom. Due to this 
lack of vitality, one is not surprised to see a slight rhinitis extend through 
the Eustachian, tube and set up an otitis media ending in mastoid infection. 
It is this class of cases which if first seen by the laryngologist will be 
treated by curetting adenoids if present, and likewise by the removal of 
tonsils if hypertrophied. 

Catarrhal Tendencies. — These cases are brought to the pediatrist weeks 
and months after such primary operation for the relief of three serious 
symptoms which were the reason for the nasopharyngeal treatment. These 
symptoms are : loss of appetite, no gain in weight, and general restlessness 
and irritability. These three symptoms stand out prominently in the picture 
which, summed together, spells faulty metabolism. 

Nervous Manifestations. — There is an irritability and sensitiveness 
simulating hysteria in the adult. Such children are easily dissatisfied. 
They cry on the slightest provocation. They are peevish and hard to phase. 
This applies not only to their clothing, surroundings and playmates, but, 
equally so. their food cravings are abnormal. They insist on sweets, also 
crave sour foods and condiments. Biting of the nails, thumb sucking and 



334 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

masturbation in the form of thigh friction may be started by an excoriation 
around the genitals and anus, caused by very acid or ammoniacal urine. 

I have been requested to examine such cases for a suspicion of tuber- 
culosis. The picture does resemble tuberculosis, although no tubercle bacilli 
exist in the expectoration. Such children will not give a cutaneous reaction 
when scarrified with tuberculin. The physical signs in the chest are 
negative, although rhonchi may occasionally be heard. 

These cases frequently have a distinct resemblance to hereditary 
syphilis. The differential diagnosis can be determined by securing an 
honest family history, and noting the presence or absence of Hutchinson's 
teeth. If still in doubt with the absence of such important data, a Wasser- 
mann reaction will aid in establishing the diagnosis. Faulty metabolism is 
an important factor in tuberculosis as well as syphilis, and the exclusion of 
such diseases must be positive. There are thousands of children whose 
sallow appearance and shriveled skin imply an abnormal state of health 
which requires vigorous treatment if results are to be obtained. 

Treatment. — If we are dealing with a distended colon or distention of 
the stomach associated with flatulence or eructations of gas, then starches 
in all forms must be excluded. Potatoes, bread, cake, and all flour foods 
must be stopped. In addition thereto all cereals such as rice, barley, and 
cornstarch must be excluded. The stool should be examined to see whether 
it contains gaseous bubbles and mucus or whether the consistency is solid. 
In a young child a strict diet of milk, eggs, and cream cheese is indicated. 
An older child, besides milk, cheese, and eggs, may have junket, custard, fish, 
meat, and all green vegetables. Stewed fruits and fresh fruits are indicated. 
The question of assimilation of food depends greatly on a regular four or 
five hour interal between each meal, with fresh air and out-door exercise, 
and not overfilling or overtaxing the stomach with large meals. 

rTux vomica in doses of 1 to 5 drops before each meal, depending on 
the age of the child, is an excellent tonic. Pancreatin in doses of 1 or 2 
grains may be combined with the nux vomica. 

The weight is an important guide as to the progress of proper metabo- 
lism. A mild laxative such as 15 to 20 grains of calcined magnesia can be 
given every morning if necessary. The child must not be permitted to 
retire without an evacuation of the bowel. One-half pint of soap-water 
may be given as an enema if necessary. 

A change of air from the city to the seashore for several months during 
winter or summer will frequently aid in establishing normal conditions. 
Some children will be benefited by a change to the mountains. The influ- 
ence of a tepid bath followed by a cool shower, or a cold bath in the morning, 
if the child can tolerate the same, is an excellent tonic. Such cool baths 
should be followed by friction of the skin to stimulate the cutaneous circula- 
tion. It is an excellent vasomotor stimulant. 



S< I i:\ v. 335 

S te of these cases may require a mild faradic current of electricity 
applied over the stomach and intestines. By Buch treatment the plexus of 
nerves is easily stimulated to advantage. The electricity should be _ . 

- vera! minutes every other day, and if well tolerated may be given daily 
for a month or more. 

Scurvy (Scorbutus: Barlow's Disease). 

This is a constitutional disease resulting from improper feeding. 

Etiology. — It usually occurs before the end of the second year, and 
rarely occurs before the first six months of a child's life. As in adults, 
scurvy is found when fresh food has been withdrawn from the dietary. It 
is natural, therefore, to look for scorbutic cases among children who are : — 

First, deprived of breast-milk. 

Second, in those brought up exclusively on milk which is devitalized by 
prolonged sterilized ion. 

Third, it is found in children brought up on condensed milk and on 
those proprietary foods to which fresh milk- has not been added. There 
seems to be, therefore, a direct relationship between the absence of fresh 
milk, be it cows* milk or human milk, and the development of this disease. 
It is a great mistake to attach importance to the fact that an infant was 
fed on a proprietary food unless we know whether or no fresh milk was 
added. It is the absence of the live factor in fresh milk which directly 
causes scurvy. 

Troup, of Christiana, quoted by Koettlitz, 1 is strongly of the opinion 
that scurvy is the result of a scorbutic element of the nature of a ptomaine 
present in the diet. Jackson and Yaughan Harley, 2 as a result of an 
experimental inquiry into scurvy, arrived at much the same conclusion. 
The question under discussion here is whether or not infantile scurvy is 
the result of the absence of some essential element in the diet or the pres- 
ence of some scorbutic factor. It is certain that an infant fed for a long 
period upon peptonized milk will develop scurvy, but if potato gruel and 
raw meat juice are added, yet no other alteration made in the diet and no 
medicine given, the scurvy will rapidly disappear and the child be well 
in a few weeks. Thus the addition of a fresh element to the scurvy diet 
has cured the condition. Moreover, many of the diets, for example, oat- 
meal and water, upon which the young children become scorbutic, seem 
to exclude the possibilities of the development of ptomaines. The experi- 
ments of Jackson and Harley do not carry conviction that true scurvy 
has been produced in animals, but rather that a condition of ptomaine 
poisoning has resulted. It is possible that unsound food may hasten the 



1 Guy's Hosp. Gazette. March 30, 1901. 

2 Proceedings Royal Society. March, 1900. 



336 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

development of scurvy, but the evidence at present seems insufficient to 
invalidate the conclusion that infantile scurvy is due to the absence of 
an anti-scorbutic element rather than to the presence of some scorbutic- 
poison. 

Summary of Essential Conditions. — The six essential conditions to be 
observed in the diet of infants are these : — 

1. The food must contain the different elements in the proportions 
which obtain in human milk. viz. : — 

Proteid 1.5 per cent. 

Eat 3.5 per cent. 

Carbohydrate 6.5 per cent. 

Salts 0.2 per cent. 

Other constituents 0.(3 per cent. 

Water S7.7 per cent. 

100.0 

2. It must possess the anti-scorbutic element. 

3. The total quantity in twenty-four hours must be such as to rep- 
resent the nutritive value of 1 to 3 pints of human milk, according to 
age. viz. : — 

Proteid 225 to 675 grains 

Eat 231 to 693 grains 

Carbohydrates G13 to 1S39 grains 

4. It must rot be purely vegetable, but must contain a large propor- 
tion of animal matter. 

5. It must be in a form suited to the physiological condition of the 
digestive function in infancy. 

6. It must be fresh and sound, free from all taint of sourness or 
decomposition. 

Pathology. — Haemorrhages in and around the joints and in the mus- 
cles are found post-mortem. The most important point, however, is the 
presence of subperiostal haemorrhage involving the long bones. Botch 
states that the femora are the most commonly affected, and that there is 
a tendency to a separation of the epiphyses. Interstitial haemorrhage in- 
volving the lungs, spleen, kidneys, and interstitial glands has been found. 
When the kidneys are involved we can usually find haematuria. Haemor- 
rhages are frequently present in the mucous surfaces : thus the gums show 
a deep purple color, besides being swollen and presenting the character- 
istic spongy appearance. 

We are indebted to Barlow for his valuable studies regarding the 
pathology and symptomatology of this disease. The blood shows no specific 
changes which are pathognomonic to this disease. 



SCURVY. 337 

Bacteriology. — No specific bacterium has as yet been found nor docs 
the blood show any peculiarities bacteriologically. 

Symptoms and Diagnosis.— The symptoms are marked irritability by 
day and restlessness at night, associated with insomnia. The mother or 

nurse will usually say that the child cannot be satisfied and cries when- 
ever touched, most especially when the anus and legs are moved. It is 
verv apparent that there is pain due to a swelling of the limbs, usually 
of the diaphyses just above the epiphyses. When not disturbed these 
children seem to lie quietly. Swelling of the limbs in the legs and fore- 
arm is usually present. While the skin over the swelling is tense there is 
no evidence of fluctuation. Tenderness on pressure is usually noted. 
Bluish-black spots, due to small subcutaneous haemorrhages, are visible. 
When hemorrhages affect the deeper parts around the eyes so that the eye 
itself will be pushed forward, a condition called proptosis will be noted. 
This condition of proptosis is found in advanced cases of scurvy. 

Owing to pain in the limbs the child does not appear to move, giving 
rise to the impression that the child is paralyzed. When this condition 
is seen in scurvy it has been called pseudo-paralysis. The gums are very 
spongy and swollen, and have bluish macules over the surfaces. The child 
shows the evidences of marked anaemia and loss of weight. There is loss 
of appetite, and when food is taken the head perspires freely. The tem- 
perature rises in the evening to between 101° and 102° F. The pulse is 
small, feeble, and ranges between 120 and 140. The respirations are not 
affected. The clinical picture is one of marked malnutrition with symp- 
toms simulating tuberculosis. 

This disease is liable to occur in either sex; it is not influenced by 
climate or locality; it is found as well in the best as in the poorest hygienic 
surroundings. By far the greatest number of cases is found among the 
rich. It is evident that this disease is due to improper feeding more than 
to an improper hygiene. Some authors believe that this disease is caused 
by a specific micro-organism; this latter fact has not yet been definitely 
settled. 

It is interesting to note the various view r s expressed by competent 
observers upon this subject; thus, while a large majority of clinicians 
hold that sterilized milk per se does cause scurvy, Botch states that it does 
not, in his own experience, seem to do so. Starr maintains just the reverse 
and believes that sterilized milk is a causative factor. From my own ex- 
perience I quite agree that sterilized milk — especially the prolonged ster- 
ilization, by which the albumins are changed, and by which this prolonged 
heating causes devitalization, which is so inimical to successful feeding — is 
a causative factor in this disease. 

It is peculiar that scurvy will be cured by giving raw milk, fresh 
fruits, and acid fruits; still we find that a great many clinicians per- 

22 



33S DISORDERS RESULTING FROM IMPROPER NUTRITION. 

sist in prescribing sterilized milk until either rickets or scurvy is estab- 
lished. It was for this reason thai at a discussion on infant feeding at 
the Academy of Medicine, October IS. 1900, I was Jed to insist on the use 
of raw mill- as the proper means of feeding children. 1 

Baw milk possesses certain advantages over boiled milk; it is more 
readily assimilated, and the proteids are not so difficult to digest. It is a 
well-known fact that boiled milk and sterilized milk have a tendency to 
produce constipation, whereas the opposite is true of raw milk. 

Improper infant food has additional disadvantages when it is sub- 
jected to excessive heating. The large number of failures with milk modi- 
fied at a laboratory are not so much due to the process involved in the 
modification as to the amount of heat that the food is subjected to prior 
to being imbibed. 

Where milk is modified for infant feeding, using raw mill- only. I 
have never seen constipation; the reverse, however, has always been true 
when milk was modified and then subjected to sterilization. The vital 
point has always impressed me as being, not so much to sterilize milk after 
it has been drawn from the cow. but to apply the principle of sterilization 
to the stable, the cow. the utensils, the milker's hands, and to everything 
coming in contact with the milk from the time it leaves the cow's udder 
until it is fed to the baby. 

When oatmeal gruel or barley gruel is given with an insufficient quan- 
tity of cows' mill- and then fed for a long time, ire must not be surpris 
to find a case of scurry. When proprietary foods are given without the 
addition of fresh mill-, then scurvy will usually result. When cream 
mixtures are given which are deficient in fat and proteids, then scurvy 
may result. Thus we find that the true, underlying cause of scurvy is 
starvation due to deficiency of one or more nutritive elements in the food 
given. 

The following case of scurvy will illustrate the condition : — ■ 

A child thirteen months old was brought to me with a history of being very 
restless and having lost considerable weight. The child showed a shriveled appear- 
ance of the skin: its normal elasticity was gone; the skin was dry. the thorax was 
pigeon-breasted: the arms and legs were thin: both arms and legs showed marked 
tenderness on the slightest motion: there was baldness at the occiput, and the 
anterior fontanel was not closed: the child had eight teeth, all of which were slightly 
carious: the gums around the teeth were deeply congested and showed bluish ridg;s: 
the gums were spongy and bled very easily: there was an intense fcetor to the 
breath: the child had been suffering from diarrhoea for the past two months, with 
occasional periods of constipation: there was no vomiting: the appetite had always 
been very poor. The previous history of the child was that, when born, it weighed 
about 5 pounds: it was very small at birth. The mother of the child died during 



^■Read also my chapter on •'•'Scurvy." in the Third Edition of 'Infant Feeding 
in Health and Disease." Published by F. A. Davis Company. 1904. 



S< URVY. 

confinement, and hence the baby was given into the care of a nursery. The diet 

- teas tonful of . milk with L2 nils of water and a 

small pinch of BUgar. This was fed every two hours for a period of over two months; 
later the child was put on barley water, to which s,>me condensed milk was added. 
This was changed from time to time to a diet oi oatmeal water and condensed milk. 

The t-hihl had always been frail, and had had a cough and also an attack 
of acute capillary bronchitis; during the summer the child had a severe at: 
cholera infantum, and almost lo-t its life from vomiting and purging. For one 
month this child subsisted on a diet of oatmeal water, rice water, farina water, and 
albumin water, besides cold tea. Tims it is -ecu that t'.ie child received no milk for 
a period of over seven weeks. When the child was live months old it weighed 7 
pound.-, and at this time it hardly weighs 10 pounds. There is a marked rachitic 
kyphosis; the ribs are beaded: there is a pendulous belly: the child has an 
umbilical hernia: the temperature, taken in the rectum at 2 p.m. for a period of 
at least two weeks, was no higher than 100° to 101° F. : there is an intense thirst: 
the kidneys are very active: the urine has a very high color: no haematuria could 
be found. 

The diagnosis of infantile scurvy was made, and the child was put on the follow- 
ing treatment: Orange juice: lemonade: freshly expressed steak juice: raw milk, 
diluted with barley water or rice water, equal parts i 4 ounces of milk. 4 ounces of 
barley water), repeated every three or four hours, depending upon the appetite. 
Ma-sage of the body was very gently performed with codliver-oil or vaseline, to 
lubricate and to nourish. A 1-drop dose of mix vomica was ordered before each 
feeding. This treatment was given continually for three or four weeks. Every 
fourth or fifth day a half-ounce of barley water or rice water was withdrawn, and 
instead an equal quantity of fresh milk was added: hence, after four weeks of 
treatment this child received 6 ounces of milk with 2 ounces of barley water or rice 
water every four hours. 

The child was sent to the seashore, and after this treatment was continued for 
seven months all symptoms of scurvy had disappeared, though the symptoms of 
rickets were still very prominent. The prognosis now is very good, and the child 
will undoubtedly recover. 

When children have walked, and suddenly stop walking and will not 
creep, then attention should be directed to the state of the gums and to 
the general physical condition. Such cases are usually suspicious, and 
show the beginning of the development of scurvy. Indeed, such symptoms 
will develop long before there is a general breaking-down. Emaciation 
and anorexia follow, which are associated in this condition. 

Differential Diagnosis. — From Rickets: This condition is easily dif- 
ferentiated. In scurvy there is no rachitic rosary. There are no ha?mor- 
rhages involving the gums nor spongy swellings found in rickets. The 
pendulous belly is usually not seen in scurvy, neither is the rachitic, square 
head frequently seen. 

From Tuberculosis. — The absence of cough and other physical siirns in 
the thorax common to tuberculosis, besides the absence of the symptoms 
above mentioned common to scurvy, will differentiate this condition from 
tuberculosis. 



340 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Scurvy and Rickets. — Both disease? may be found at the same time 
in the child, and are evidently due to disturbances of metabolism founded 
upon dietetic errors in which the absence of the live factors in food has 
been neglected. 

Prognosis and Course. — The course of the disease is usually chronic. 
I have seen cases of scurvy wasted to skin and bone, when hardly any mus- 
cle was left, and the fat almost gone and the elasticity of the skin lost. 
In spite of this shriveled condition, with proper feeding, in a few months' 
time, wonderful changes were made. I do not regard a case of scurvy as 
hopeless if some vitality remains. We must be exceedingly persistent and 
patient, and continue the treatment for weeks and months. 

Treatment. — The most important part of the treatment of scurvy con- 
sists in eliminating the antiscorbutic elements by proper feeding. 

Dietetic Treatment. — Antiscorbutic diet consists of fresh milk, fine 
potato gruel. 1 raw meat, raw yolk of egg, orange juice, and sugar. 

Fresh milk is clearly not a potent antiscorbutic, and. although suf- 
ficient to prevent scurvy when given in full quantity, will not always pre- 
vent it when taken in small amounts only. It fails accordingly to remove 
the scorbutic condition with quickness and certainty when given alone. 
It is necessary, therefore, to add to the food some more active agent, such 
as potatoes, carrots, or a vegetable juice, as orange juice. Malaga grapes, 
or a broth in which vegetables, such as carrots and potatoes, have been 
boiled and strained, with raw meat juice -in addition. 

In addition to the rigid enforcement of the above-mentioned foods, 
we must insist upon fresh air. 

Hygienic Treatment. — Besides having fresh air. a child suffering with 
scurvy must be put directly into the sun. This sun bath should be admin- 
istered for hours at a time. Proper ventilation of the sleeping apartment 
is very important. A scorbutic child requires a daily bath consisting of 
one pound of sea salt to a tub of water at a temperature of 95° F. The 
child should be bathed from three to five minutes and rubbed briskly while 
in the tub. After the bath the body should be dried with a coarse towel 
and rubbed until the skin has a pinkish color. This friction or massage 
is very invigorating, and if done in the evening it will promote sleep and 
soothe the child. 

Medicinal Treatment. — Eestoratives, such as pure codliver-oil. lipa- 
nine. or morrholine. given in doses of a teaspoonful two or three times a 
day. are indicated. Iron, such as syrup of the iodide. 10 to 30 drops, three 



1 Prepared by rubbing thoroughly steamed floury potato through a fine sieve, 
and beating this up well with milk until it is smooth and of the consistency of thin 
cream. A teaspoonful of this may be added to each bottle at first, and the amount 
gradually increased to a dessertspoonful, if it is found to agree. Well-boiled carrots 
may be used in the same way. 



RACHITIS. :;il 

times a day, or tincture ferri acetic- ether, lo to £0 drops, three times a 
day. may be given. Malt extract contains a live factor, and is therefore 

very valuable as an antiscorbutic restorative; it should be given in doses 
o( a teaspoon Tub two or three times a day, or until the bowels are loose, then 
the dose must be reduced. 

Maltine is one of our best preparations and has served me very well 
in scurvy. The successful outcome of the treatment of a case of scurvy 
depends on judicious feeding aided by the above-named associated con- 
ditions. 

Eaciiitis (Rickets). 

liickets is a disorder of nutrition. It occurs chiefly between the ages 
of 6* months and 2 years. Congenital rickets is occasionally seen. It 
affects the bones primarily, and these are very readily distinguished during 
life. The disease also affects the ligaments, the mucous membrane, the 
muscles, and especially the nervous system. 

Pathology. — The lesions are chiefly noticed in the bones, although 
the soft tissues show evidences of ana?mia. The primary lesion is hyper- 
emia of the periosteum, the marrow, the cartilage, and the bone. The 
spleen and liver are usually enlarged. Frequently we note enlargement of 
the lymphatic glands. 

Starck found the spleen enlarged in 50 per cent, of his autopsies in 
rachitic children, and in 68 per cent, of all his living cases. In the kid- 
neys there are usually no pathological lesions. The cartilage cells of the 
epiphyses undergo increased proliferation from four to ten times more 
than they do in a normal growing bone. The matrix is softer; as a result 
the bone formed from this abnormal cartilage lacks firmness and rigidity. 

The increased proliferation of cells makes the epiphysis larger, swollen 
in appearance, irregular in outline, and much softer in consistence. It has 
been experimentally proven that hyperemia of bone causes defective de- 
compositions of lime salts. Owing to this deficiency of lime salts the bones 
become very toft and flexible. While normally there is two-thirds mineral 
matter in the bones, in rickets this is reduced to one-third. Thus we can 
easily explain the various "rachitic deformities" which are especially noted 
in the femur, the tibia, the radius, the ulna, and the ribs. When ossifica- 
tion is retarded during rickets, as, for example, in the parieto-occipital 
region, the bone is frequently so thin that it yields to pressure; this is 
called craniotabes. 

The fontanels are not closed until very late owing to this delayed 
ossification. The frontal and parietal protuberances are very much en- 
larged, due to exaggerated proliferation of the periosteum, so that the 
head acquires a broad forehead with characteristic frontal prominence. 
This condition is frequently taken for hydrocephalus. When ossification 



342 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



takes place the bones become large, heavy, and irregular in outline, corre- 
sponding to the clinical manifestations known as '•bow-legs." -knock- 
knees/' "pigeon-breast," ''"spinal curvature/*' and '"square cranium." 

Where the bone joins the cartilage, as. for example, on the ribs, en- 
largements occur which simulate beads ; hence the term "beaded ribs." also 




Fig. 92. 



Fig 93. 



Fig. 92. — Case of Hydrencephaloid (Spurious Hydrocephalus). Infant 
8 months old. Bottle-fed. Suffering with cholera infantum. Severe nervous 
and toxic symptoms, 

Fig. 93.— Same Child Two Years Later. Note the square head, the 
frontal protuberance. Also the Harrison's groove and the pendulous belly. 
The picture illustrates the cranial, thoracic and abdominal type of rickets. 
(Original.) 



called "rachitic rosary." The same enlargements can be felt at the wrist-. 
ankles, and knees. 

A section through the epiphyseal junction of a rachitic bone shows a 
very vascular, bluish-colored condition, which is softer than normal when 
cut. In the shaft next to the periosteum the bone is soft and thickened, 
but deeper it is hard. Sections through thickened masses on the flat bones 



show a spongy 
easilv. 



vascular substance which is 



soft enough to 



be indented 






UAUI1T1S. 



343 



Microscopical examination shows a marked increase in new cartilage 

cells and increased vascularity of the proliferating zone. The areas which 
should be calcified show large quantities of cartilaginous tissue instead. 
The under-layer of the periosteum is very vascular, and again there is a 
greal excess of uncalcified cartilage. In the Hat hones the bony trabecular 
are eroded, and their places taken by newly formed minute blood-vessels. 
When the rachitic process ceases and recovery begins, this excessive 
proliferation stops. Calcification and ossification of these tissues take 
place; the enlargements due to the hyperplasia are absorbed, and the bone 
returns to a normal condition save for any deformities that may have re- 
sulted during the activity of the rachitic process. 




Fig. 94 — A Case of Spurious Hydrocephalus, Illustrating Marked Fron- 
tal and Parietal Protuberances. There was a striking resemblance to a 
case of hydrocephalus. Bottle-fed. Rachitic. (Original.) 



Chidren that have suffered prolonged diarrhoeas or with severe dis- 
eases — like dysentery, typhoid, bronchitis, and pneumonia — are prone to 
the development of rickets. Children of syphilitic parents and those whose 
parents are tuberculous are more prone to the development of this disease. 
Von Ritter, quoted by Professor Baginsky, says that, in 27 cases out of 71 
examined by him, rickets was not only found in the children, but as well 
in the mothers of these same cases. Thus it is that Kassowitz and Schwarz 1 
have mentioned the existence of congenital rickets. These same authors 
found that 80 per cent, of children born in the Vienna Lying-in Hospital 
were rachitic. This statement is not so easily accepted, however, for neither 

^Viener medicinische Jahrbucher, 1887, vol. viii. 



344 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Professor Baginsky nor Virchow accept the same. Experimentally, it has 
been found as long ago as 1842 by Chossat that when lime is deducted 
from the nourishment of young animals not only soft bones result, but they 
finally die. Heitzmann maintains that, if lactic acid is introduced into 
the food of young animals, the result will be, first, rickets, and, later 
on, osteomalacia will result therefrom. Clinical investigations have shown 
that cases of rickets occur more often during the winter months; thus it 
is apparent that improper ventilation is one of the most exciting causes of 
this disease. 

"When children are improperly fed so that the body is underfed, .mus- 
cle and bone formation will be slow. The eruption of the teeth will be 
delayed, and this is one of the most prominent symptoms of rickets. The 
bones show the most characteristic result of improper nutrition, for they 
are very soft and spongy. They will yield to the weight of the body if used 
in walking, and thus it is that bow-legs with extensive curvatures form 
such a prominent feature in showing the result of using soft bones. The 
most typical symptoms can be studied on the head and spine. Thus, 
craniotabes can be explained by a deficient nutrition in which the cranial 
bones will be found so soft that they will yield to the pressure of the thumb. 
The cranial bones will frequently be found to be as soft and as thin as paste- 
board. The spine is frequently deformed, and will show a typical rachitic 
kyphosis. 

Causes. — The absence of human milk from the diet of an infant is 
one of the prime reasons for the development of rickets. We therefore find 
more than 90 per cent, of all cases of rickets among the bottle-fed babies. 
Other contributing factors are the absence of sunshine and the crowding 
of large families into small rooms having poor ventilation. Eickets will 
occasionally be seen in the breast-fed child. If the mother while nursing 
suffers with malnutrition, malaria, chronic cough, or with any organic 
lesion which devitalizes the body, then poor breast-milk deficient in its 
nutritive elements will cause the body to be underfed and finally result 
in rickets. 

Breast-fed children will sometimes show rickets when they have been 
living in bad apartments, breathing foul air, and not being properly cared 
for. One of the most frequent causes of rickets is "prolonged" nursing. 
In the section on "Breast-feeding" I have already pointed out the neces- 
sity for making a proper chemical examination of the breast-milk if the 
infant "shows no increase in weight." We know that, toward the end of 
lactation, not only do the proteids diminish, but get to such a low per- 
centage that, unless we combine hand-feeding by adding the raw yolk of 
egg, steak juice, and other proteids, like the cereals, to the breast-feeding, 
the child will be underfed. Underfeeding is certainly a contributing factor 
to the causation and the development of rickets. 



RACHITIS. 



345 





Fig. 95. 



Fig. 96. 




Fig. 97. Fig. 98. 

Illustrating Rachitic Erosions of the Permanent Teeth.' 



*I am indebted to Dr. Hugo Neumann, Privat-dozent in Berlin, for the above 
illustrations. 



346 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Symptoms. — One of the first symptoms noted is constipation. When 
there are evidences of gastric disturbances, unless properly treated, chil- 
dren will be underfed and rickets will result. Plead sweating, especially at 
night, is an early symptom of rickets. Boiling of the head on the pillow, 
with occipital baldness, frequently precedes the development of rickets. 
Pallor of the skin and profound anaemia frequently precede or accompany 
the development of rickets. Rachitic changes affect the fontanel and the 
sutures, as well as the whole of the bones of the cranium. The rhombic 
form assumes an irregular outline. The sutures, especially the lamb- 
doidal and frontal, are distended. 

The fontanel remains open much longer than in normal infants, so 
that not infrequently the anterior fontanel can still be felt slightly open 
as late as the third or fourth year of life. Although the usual type of 
rachitic head is square, not infrequently it assumes an asymmetrical form. 




Pig. 99. — Rachitic Ribs. Incurvation of the ribs at the osseous-cartilaginous 
junction in rickets. One-half natural size. ( Langerhans. ) 

We are indebted to Elsasser for a description of one of the most valu- 
able symptoms in rickets, namely, "softening of the cranial bones," known 
as "craniotabes." Small areas of softened bone which will yield on the 
slightest pressure can be felt in the region of the lambdoidal suture. 

Early symptoms of rickets also are tetanic seizures, muscular spasms, 
and laryngeal spasms. Dentition is delayed, the teeth appearing irregu- 
larly, and in older children they are carious. Xot infrequently we find 
no evidence of teeth until the child is 1G or 18 months old. Rachitic symp- 
toms appear later in the thorax than in the head, although they can be 
plainly made out during the first six months. Beaded ribs are especially 
prominent in advanced cases. There is a marked depression of the thorax 
in a line parallel with and on either side of the sternum. This line cor- 
responds with the course of the beads. The so-called pigeon-breast or 
funnel-breast (pectus carinatum) is frequently observed in rickets. 

The veins of the scalp are usually enlarged. Spinal rickets is espe- 
cially characteristic. The posterior curve of the spine is commonly known 



RACHITIS. 



347 



is rachitic kyphosis. It extends from the middle-dorsal to the sacral 




Fig. 100.— Case of Rickets Showing Enlarged Spleen; also Pendulous 
Belly. (Original.) 

This kyphosis has been found in more than one-half of my cases. The 
curve can be lessened or it will disappear when the child is placed on its 
back and extension is made on the extremities. The more important 
rachitic deformities are : — 

1. Rachitic kyphosis. 

2. Rachitic scoliosis. 

:5. Chicken (or pigeon) chest. 

4. The rachitic pelvis. 

5. Cubitus valgus or varus. 

6. Distortion of the lower extremities : — 

(a) Genu varum. 

(b) Genu valgum. 

(r) Anterior curvature oi the tibiae. 

(d) General distortion- of the lower limbs. 



348 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



Diastasis of the Recti Muscles in Rickets. — When the muscles lose their 
tone, we frequently have the bony changes soon afterward. Diastasis of the 
recti muscles of one-half or one inch can sometimes be made out. To pro- 
perly examine a child for this condition it should be laid on its back with the 
head and shoulders elevated, thus the recti muscles will relax and a pro- 
trusion of the abdominal contents in the median line can be noted. 

The clavicle is affected only in severe cases. Not infrequently there 
may be a green-stick fracture. I have frequently noted the exaggeration 
of the anterior curve at the inner third of the bone which is described by 
Holt. There are various pelvic deformities such as the narrowing of the 

subpubic arch. There is also a contraction of the 
antero-posterior diameter of the pelvic bones. 
For further details I will refer the reader to Gar- 
rigues' "System of Obstetrics." In girls the 
neglect of rickets in infancy may meair serious 
trouble in womanhood if pregnancy occur. 

Extremities. — It is not difficult to note de- 
formities in the humerus. The epiphyses, as in all 
long bones, are thickened and enlarged. The 
thickening of the epiphyses in the radius and ulna 
is readily made out. The shafts of these bones 
describe a convexity upon their extensor surface. 
Green-stick fractures are very common in these 
bones. The ends of the metacarpal or of the 
phalanges are sometimes enlarged. 

Tlie Lower Extremities. — The outward bend of 
the tibial and in marked cases of the femoral 
produce the condition known as bow-legs (genu 
varum). (Fig. 103.) In these cases when 
the feet are put together the knees are far 
apart. The opposite condition known as knock-knee (genu valgum) 
may exist The inner condyles of the femur are hypertrophied, so 
that when the knees are put together the feet are far apart. Knock-knees 
are more common in females. The ligaments around the joints are relaxed 
and weakened, so that from an anatomical standpoint they assist in pro- 
ducing this deformity. The muscles show marked evidences of this disease. 
They are flabby, soft, and small with poor development. This accounts for 
the lateness in walking. The muscular power is very feeble, and not infre- 
quently paralysis will be suspected when really we are dealing with ag- 
gravated rachitic muscles. 

Malnutrition is plainly made out on studying these emaciated, anaemic 
children whose bones are markedly rachitic. On the other hand we fre- 
quently find very fat children with extreme pallor showing marked rickets. 




Fig. 101. — Five-weeks 
old Fracture of the Hum- 
erus, in a Rachitic Child 
1 y 2 years old. ( Langer- 
hans. ) 



a 



^^&WW3 



RACHITIS. 



349 



PiPlllflP* 




Fig. 102. — Rickets. Longitudinal section through the ossification junc- 
tion of the upper diaphyseal end of the femur of a one-year-old child suffer- 
ing from rachitis of moderate degree, a, Unaltered hyaline cartilage, b, 
Cartilage in the first stage of proliferation, c, Zone of proliferated cartil- 
age cell columns, d, Columns of proliferated hypertrophic cells, e, vessels 
located in the cartilage, with fibrous marrow tissue, f, Decalcified cartilage 
tissue, g, Osteoid tissue, h, Remains of cartilage tissue in osteoid tissue. 
i, Trabecular of decalcified osteoid tissue, k, Trabecular of osteoid and fully 
formed calcified bone tissue. I, Fibro-cellular marrow tissue. (Ziegler.) 



350 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



Therefore, a fat infant is not necessarily a healthy infant. The abdomen 
is enlarged and usually tympanitic on percussion. It is commonly known 
as the "pendulous belly." This latter symptom I met with in fully 90 
per cent, of my cases in a large children's service extending over many 
thousand cases. I have rarely failed to note the distended belly in rickets. 
The loss of tone in the abdominal muscles, and especially in the muscular 




Fig. 103.— A Severe 
Type of Rickets With 
Enlargement of Both 
Condyles of the Femur. 
There is also enlargement 
of the upper epiphyses of 
the tibia and fibula. The 
illustration also shows 
enlargement of the epi- 
physes of the ankles. An 
antero posterior curva- 
ture (giving the bow-leg 
appearance) is plainly 
seen. Note also the en- 
larged epiphyses of the 
radius and ulna. Drawn 
fro m a photograph. 
(Original.) 



walls of the stomach and intestines, is one of the prime reasons for con- 
stipation. Occasionally the reverse may be true and diarrhoea may be 
noted. There is frequently marked distention of the stomach and colon. 
The stools are hard and dry, causing a chronic catarrh of the colon. We 
frequently find at the end of the stool a large amount of glairy mucus. 
The pulse and temperature are normal. Occasionally a bruit can be 
heard over the anterior fontanel. It has no special significance. There 
is nothing characteristic in the urine in rickets. The blood has been 
studied by Morse, who concludes that anaemia is present in most cases. 
Its intensity varies with the intensity of the rachitic process. Leucocytosis 
may or may not be present. An enlarged spleen is met with in these cases. 



RACHITIS. 351 

Convulsions and spasms of various descriptions occur frequently in 
rickets. There seems to be a predisposition to general tetany, and to laryn- 
geal spasm (laryngismus stridulus). The general weakness of the body 
is also seen in the marked tendency to irritation in the nerve centers. 
Most discuses in rachitic children are ushered in with convulsions, thus 
showing the extreme sensitiveness and susceptibility of the nerve centers. 
An overloaded stomach in a rachitic child under 1 year of age, suffering 
with high fever, is usually attended with hyperpyrexia and convulsions. 

Diagnosis. — This is usually very easy. Head sweating, constipation, 
restlessness at night, delayed dentition without palpable osseous mani- 
festations usually mean rickets. The most prominent symptoms are beaded 
ribs, enlargement of the epiphyses of the wrists and ankles, kyphosis of 
the spine, and bow-legs. 

Differential Diagnosis. — The rachitic head is sometimes mistaken for 
hydrocephalus. The electrical reaction will decide whether or no we are 
dealing with a poliomyelitis, or if the case is a pseudo-paralysis with 
rickets. We must differentiate the bony enlargements of syphilis from 
rickets by remembering that the bony changes in syphilis affect the shaft 
of the lone rather than the extremities as previously described. An im- 
portant point to remember is that in syphilis there may be necrosis. This 
is never seen in rickets. The differential diagnosis will best be made by 
obtaining a complete clinical history and eliminating all doubtful symp- 
toms. Scurvy is easily differentiated from rickets by the spongy condition 
of the gums, by the tendency to haemorrhage, and usually also by the 
presence of ecchymotic spots. The diagnosis of rachitic kyphosis 'from 
spinal tuberculosis (Pott's disease) is easily made, although I have seen 
one case in which there existed a rachitic kyphosis in a tuberculous child. 

Prognosis and Course. — Eickets, per se, is rarely fatal. The active 
symptoms exist about one or two years; in rare instances for many years. 
Permanent damage of the system may remain throughout life. Spinal 
curvatures and thoracic deformities will remain for many years. 

Eachitic children when attacked by infectious diseases suffer far 
more and the prognosis is graver than it would be otherwise. The abnormal 
condition of the thorax in rachitic children must always be taken into 
consideration in a child suffering with pneumonia, pleurisy, or other pul- 
monary conditions, in estimating the outcome of the disease. 

Treatment. — Prophylactic Treatment : The preventative treatment of 
rickets consists in giving the infant healthy surroundings, plenty of fresh 
air, and by all means human milk of the required quality and quantity. 

Hygienic Treatment. — When rachitic conditions are established the 
first thing to do is to insist upon removing such children to healthful sur- 
roundings. When children are housed in poorly ventilated homes, dark 



352 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

rooms, without sunshine, it is useless to give medicine until the unsani- 
tary surroundings are improved. Successful treatment in such cases de- 
mands plenty of sunshine, open windows, night and day, a tub bath with 
a handful of sea salt added every day. After the bath good brisk rubbing 
to stimulate the circulation is very necessary. A change of air from the 
city to the country is desirable. When we are prescribing for the poor 
they should be instructed to remain in the park as much as possible. The 
establishment of small roof gardens on the tops of the highest dwelling or 
tenement houses makes a cheerful place for the rachitic children to play. 
Dietetic Treatment. — Next to hygienic methods the care of the diet 
is important. If a nursing infant shows rachitic symptoms the chemical 
examination of the breast milk, as outlined (see chapter on "Chemical 




Fig. 104. — Rickets. Showing Beaded Ribs and an Enlarged Pendulous 
Belly. Mouth-breather due to adenoids. Breast-fed infant. Always lived 
in tenement house district. Mother very anaemic. (Original.) 

Analysis of Breast Milk"), should be determined. If we find low proteids 
the nursing mother or wet-nurse should be given more meat, eggs, and 
cereals. If, however, conditions exist which prevent proper nursing, the 
child should be weaned. A properly modified cows' milk adapted for the 
age and development (see chapter on "Infant Feeding") should be sub- 
stituted. When rickets exist, proteids are demanded. I insist on feeding 
such children with cereals, such as barley, rice, cream of wheat, sago, 
farina, etc., and giving them plenty of fresh vegetables, such as spinach, 
asparagus, peas, and beans. Eggs, white meats, and fish may be given if 
children are old enough. Fresh fruits must not be forgotten. Butter and 
cream are valuable adjuncts to the dietary. 

Medicinal Treatment. — In addition to the importance of proper feed- 
ing we must seek to establish proper metabolism. All the emunctories 
must be carefully watched. Drug treatment should be directed to supply- 



RACHITIS. • 353 

lug the deficient amount of lime in the bones. The glycerophosphate of 
lime which has been used by me for several years, in closes of 1 to 5 grains, 
three times a day, is very useful. Codliver-oil or morrholine, to which 
V200 grain of phosphorus is added, has served me very well in some in- 
stall ees. This phosphorized codliver-oil must be freshly prepared, as it 
deteriorates on standing. Quite a discussion as to the value of phosphorus 
has arisen abroad during the last few years. Monti, of Vienna, and Bagin- 
sky, of Berlin, and Zweifel, of Leipzig, deny the medicinal virtue of phos- 
phorus in rickets. The claims of Kassowitz, of Vienna, the originator of 
this treatment, have not proven successful in my hands. Hundreds of 
children in the crowded sections of the city have been put on the phosphor 
treatment. When codliver-oil was added to the phosphor, good results 




Fig. 105. — Rickets. Note Beaded Ribs on Left Side of Thorax. (Original.) 

were noted, not otherwise ; so that I believe it is the codliver-oil rather than 
the phosphor that possesses medicinal virtues. Fellows\ syrup of hypos- 
phi tes, arsenic, iron, and strychnine have served me very well, especially 
when atony of the stomach or dyspeptic conditions existed. The careful 
regulation of the bowels and good action on the part of the kidneys and 
skin will greatly aid in modifying rickets when established. 

Treatment of Deformities. — Kyphosis: . In rachitic kyphosis a Brad- 
ford frame or a similar appliance is indicated. A spinal brace will some- 
times do good. Massage with good friction will develop a weakened spine 
in some cases, and plaster of Paris jackets may be serviceable. Manual 
correction of the deformity will aid in the treatment. 



History of Rickets in Infancy. — A very antemic, poorly developed girl. Brought 
up in a tenement house in the thickly crowded portion of New York City. Was 
breast-fed during infancy, fifteen months. Had summer complaint. Dentition began 
at eight months, walking at sixteen months. Very bright mentally. Is very 



354 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



restless, at night, nervous choreic twitching during the day. No mammary 
development, no evidence of menstruation. 

Father and mother of this child are apparently well, though dyspeptic. No 
evidence of syphilis or tubercular disease. This child has had tonsillar infections 
several times each year; had diphtheria, measles, and scarlet fever. Has diarrhoea 
whenever nervous or frightened. 

Since instituting gymnastic exercises, the muscles of the hack have been 
greatly strengthened, although the spinal deformity has not been lessened or 
improved. 

The main treatment consisted in fresh air, out-of-door exercise, diet of milk, 
cream, butter, fruits, cereals, and meats. Stop school and all studies. 




Fig. 103. Fig. 107. 

Fig. 106. — Rachitic Kyphosis (Spine) . Permanent deformity. Rachitic 
thorax in school girl, 12 years old, showing Harrison's groove, and funnel- 
shaped depression of sternum. 

Fig. 107. — Back View Same Child, Showing Rachitic Kyphosis. This 
deformity is the permanent result of rickets in infancy. It is to be differ- 
entiated from Pott's disease. Note also the curvature of the spine. 
(Original.) 



Medication, codliver-oil, malt, glycerophosphate of lime and soda, raw eggs, 
wine in moderation. Cool sponging with sea salt. Friction of body after gymnastic 
movements. 

Scoliosis (Lateral Curvature) and Lordosis (Forward Curvature of 
the Spine). — The management of these conditions is similar to that described 
for kyphosis. 

Cubitus, Varus, and Valgus. — These deformities disappear as a rule 
without special treatment. 



RACHITIS. 355 

Bow-legs (Genu Varum ^.-^This common rachitic distortion may be 
congenita] or it may be an acquired condition. The treatment consists in 
support and correction by braces. 

Whitman believes that correction by osteotomy or osteoclasis is neces- 
sary when children are over 5 years of age. For knock-knees braces are 
usually necessary. The Thomas knock-knee brace is the most efficient. In 
some cases osteotomy of the femur just above the epiphyseal line is indi- 
cated. 

Antero- posterior how-leg can only be corrected by osteotomy. 

Genu Recurvatum (Back-knee). — Whitman states that in its most 
extreme form it is of congenital origin, and is usually associated with 
defective development of the anterior thigh muscles and of the patella. 
In such cases the knee is bent directly backward, and the tibia is often dis- 
placed forward upon the femur. In the milder types of back-knee there 
is simply an abnormal or over-extension caused by laxity of the ligaments 
and supporting muscles. This form is usually secondary. It is often seen 
in cases of hip disease after prolonged mechanical treatment. It may be 
associated with congenital talipes, or it may be the direct result of paral- 
ysis of the muscles of the legs, or even of general weakness, as in severe 
rachitis. 

The following are the principal points in the differential diagnosis of 
rickets and Pott's disease : — 



Table No. 56. 



Rickets. 



Deformity not angular. 

Result of posture. 

Evidences of rickets elsewhere. 

In infancy. 

In middle and lower part of the spine. 

The body may be bent forward with- 
out discomfort. 

The curve is lessened, or it may be 
obliterated when the trunk is ex- 
tended. 



Pott's Disease. 



Angular. 

Result of lesion. 

Absent. 

Usually later. 

In any part. 

Forward flexion causes pain. 

Never disappears. 



Surgical Treatment. — Jt is always safe advice to consult a surgeon or 
orthopaedist concerning deformities in early life. Very many rachitic de- 
formities due to softened diapheses can be corrected or modified as de- 
scribed in the treatment previously given. "When a brace appears unsatis- 
factory then surgery may yield excellent service, but surgery must be used 
in conjunction with proper nutrition and restorative treatment to secure 
permanent benefit. 



35G DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Atheepsia Infantum (Infantile Atrophy, Decomposition, 
Marasmus, or Wasting Disease). 

This condition is met with as a result of malassimilation of food. It 
is really a deficient metabolism, and results in a gradual decline. It is 
important to note that constitutional disorders, such as tuberculosis or 
syphilis, are not the causative factors. 

When the digestive function is impaired and food is not assimilated, 
then wasting follows. An inquiry into the cause leading to this disturbance 
is naturally of interest, as thereby we can frequently find therapeutic 
measures necessary to modify and frequently to cure this disease. 

Etiology. — What are the causes? 

1. Improper food. (a) Over-feeding; too rich food. (b) Under- 
feeding; lack of nutriment. 

2. Bad hygiene. 

3. Too frequent feeding; improper quantity. 

4. Congenital defects, (a) Harelip, (b) Adenoids. 

5. Inherited diseases. 

6. Improper development. Premature birth and its consequent sub- 
n formal digestive powers. 

7. Sequela? to acute infections; subsequent paralysis preventing proper 
digestive functions. 

Henoch does not like the term "athrepsia" introduced by Parrott, but 
prefers "atrophy." The first symptom that this author noticed is that the 
child's weight does not increase ; hence he emphasizes the importance of 
frequently weighing children. He regards the weight taken once a week 
as sufficient, so that it can be the determining factor as to the progress made 
by an infant. Henoch says that at the end of the first month the weight 
is increased one-third, at the end of the fifth month it is double, and at 
the end of the twelfth month it is three times the weight at birth. Wean- 
ing, dentition, and all other pathological conditions interfere with a proper 
increase in weight. 

By far the greatest number of cases of athrepsia are found in bottle- 
fed children. There are, however, a great many cases to be seen among 
breast-fed children. We can then be positive that the breast-milk is lack- 
ing in some of its chemical constituents, and frequently we find that it is 
the proteids that are deficient in quantity. If, therefore, we meet with a 
case of athrepsia in a breast-fed child, the thing to do is to have a chemical 
examination made of the breast-milk. If it is found deficient in quality, 
then we must withdraw it and substitute bottle-feeding. 

A great many children will be found to thrive at once after having 
been removed from the breast and changed to some artificial mode of feed- 
ing, whereas the reverse is also true. If we wish to discard the mother's 



ATHREPSIA INFAML'M. 

milk, for some positive reason, then it is advisable to secure a wet-nurse 
having a child as near as possible to the age of the one she is about to suckle. 
The hereditary history oi a nurse is of great importance, a< is also the 

quality and quantity of her milk, which should be thoroughly examined 
before she is given this foster-child. (Head chapter on "Wet-nura 

Pathology. — There are no distinct lesions which can be called specific 
in marasmus. In some there may be a fatty liver associated with a gen- 
eral tuberculosis. The brain is commonly an&nnic with dark fluid blood 
in the sinuses, marantic thrombi being rare. In many young infants areas 
of atelectasis are found in the lower lobes. The heart, spleen, and kidneys 
are pale, but otherwise normal. The solitary follicles of the colon, the 
small intestines, and sometimes Peyers patches are slightly enlarged, the 
mucous membrane in other respects being: normal. The mesenteric glands 
are often slightly enlarged ( Holt ) . The true pathology seems to be a 
failure to assimilate food in infants with improper hygiene, and as a result 
progressive emaciation takes place. 

Symptoms. — When infants suffer with vomiting or diarrhoea, and this 
condition is allowed to become chronic, then colic and flatulence, associated 
with constipation, supervene, and the result is a gastro-intestinal catarrh. 
Neglect of this condition means the development of the condition known 
as athrepsia. The infant does not thrive, commences to waste, and unless 
we realize the condition and give the baby proper treatment, such a child 
will die from exhaustion and from inanition. TVlien these cases linger for 
months they develop rachitis. Eecovery without treatment is impossible. 
Parrott was the first to define this disease and classify it into three 
stages : — 

1. The infant suffers from a simple diarrhoea or looseness of the bow- 
els. The stools, instead of being bright yellow and homogeneous, are liquid. 
curdy, often of a greenish color, and contain an excessive quantity of mu- 
cus. The abdomen is distended with gas and remains constantlv in this 
condition. The tongue is coated and the patches of a stomatitis appear in 
the mouth. The infant is restless, constantly whining, and will not sleep 
at night. The milk, being retained, curdles: the tissues become flabby, 
and wasting commences. 

2. The symptoms are intensified and the characteristic wasting be- 
comes manifest. The ate \s 3 for the most part- ar e loose and frequent, and 
consist of undigested food. The stools are frequently pale and putty-like, 
with a peculiar odor. At other times they are dark brown from the pres- 
ence of altered bile. The infant is most voracious, liquid food does not 
seem to satisfy it. and by the mistaken kindness of its friends it is fed with 
some thick food like soft bread, a diet which has the great advantage in 
their eyes of keeping it quiet for a longer time than liquid food or diluted 
milk. At times it can hardly be made to sleep, or only dozes for a short 



358 



DISORDERS RESULTING FROM IMPROPER NUTRITION. 



time, unless under the influence of a soothing syrup given by its nurse. 
The mouth becomes the seat of a parasitic stomatitis; the skin is harsh 
and dry; small boils or a lichenous rash make their appearance. The but- 
tocks and genitals are raw and excoriated. The temperature is below nor- 
mal; the feet and hands are congested; the face has a pallid, earthy tint, 
and a sickly lactic-acid smell is given out from the body, especially the 
abdomen. The wasting is extreme, the face being shriveled, the skin 
wrinkled and hanging in folds about the arms and thighs. 




Fig. 108. — Athrepsia Infantum. The loss of fat causes the skin to 
hang in loose folds. Note the left forearm and both legs. The forehead 
is wrinkled. The hand in the mouth is a characteristic symptom of 
starvation. (Original.) 



3. The third stage brings the child into a moribund state. It is too 
feeble to cry, becomes heavy and drowsy, taking little notice of anything. 
Death then ensues, probably preceded by a muscular twitching, strabismus, 
or general convulsions. 

Prognosis and Course. — The course of this condition depends on the 
amount of nutrition that can be assimilated. The worst forms of marasmic 
children will frequently gain in weight when proper food is given. If the 
appetite is poor a decided change of air, from the city to the country, or 
vice versa, will strengthen the infant and restore the appetite. Many a 
child's life has been saved by a trip to the seashore or a sea voyage. The 



ahum: ps i a infantum, 



359 



outcome of the case depends on judicious feeding, a change of air, and 
proper hygienic management. 

The treatment of this disease is one thai resolves itself into removing 
the cause, and it' bad hygienic surroundings — as impure air, crowded apart- 
ments, and improper diet — are the cause, then these must be remedied at 
once. Medication" amounts to nothing in the treatment of this disease. 
With hand-fed or bottle-fed children we can easily regulate the condition 
of their bowels, and also easily regulate the quantity and the quality of 
food given them. The blandest and least irritating food must be selected, 
while frequent weighing of the infant should be resorted' to in order to 
ascertain the progress that is being made. 




Fig. 109. — Athrepsia Infantum. The emaciation is seen on the neck, 
right arm, the thighs, and legs. The tendons on the right foot are plainly 
seen. (Original.) 



In some children milk or milk foods are badly assimilated and gastric 
symptoms follow ; it may be wise to discontinue milk for several weeks. 
By this means we give the stomach absolute rest and can order food that 
is more easily assimilated until such time when milk may again be tole- 
rated. My plan has been to order whey made by straining the curd out of 
milk (see "Dietary*") : 6 to 8 ounces of whey may be given, to which the 
yolk of a raw egg may be added. Concentrated chicken soup thickened 
with sago, farina, or barley may be given in quantities of 4 to 6 ounces 
alternating with whey. A child of 1 year may be fed every three hours if 
marked emaciation exists. The value of vegetable soups, such as pea, bean, 
or lentil soup, strained, must not be forgotten. Eoasted flour made as a 
flour ball (see page 77) may be added in the proportion of a teaspoonful 
to 4 or G ounces of soup. An emulsion of sweet almonds may be tried as a 
valuable and nutritious vegetable proteid. Steak juice, roast beef juice, or 
beef blood is indicated in doses of 2 to 6 ounces, once or twice a day. 



360 DISORDERS RESULTING FROM IMPROPER NUTRITION. 

Where there is much diarrhoea milk must be used sparingly or alto- 
gether omitted for a while, as the hard curds formed in the stomach are 
beyond the feeble digestive powers of the weakened stomach and intestines. 
Small quantities of whey and barley water, yolk of egg and barley water, 
or the juice of a rare chop or steak may be given at short intervals during 
the day and night. 

As soon as the child improves in respect to the diarrhoea, milk in some 
form may be allowed. Peptonized milk is often of much value in these 
diseases when made by mixing 3 ounces of cold milk, adding 2 tablespoon- 
fuls of cream, with half of a peptonizing powder. In addition to the above 
the white of a raw egg or the yolk of an egg may be well beaten up with 
water and given in teaspoonful doses. When the stomach rejects all food, 
rectal feeding may be resorted to (see chapter on "Kectal Feeding"). High 
saline injections will be urgently called for in this wasting condition. They 
may be repeated, if beneficial, two or three times a day. Several pints of 
saline solution may be slowly injected. 

Bestorative treatment will consist in giving small doses of codliver-oil, 
iron, malt, and arsenic if the stomach will tolerate the same. The inunc- 
tion of warm codliver-oil over the entire bod} r every morning is frequently 
of service. The outcome of the case usually depends on perseverance and 
judicious feeding. 

Marasmic and atrophic children do well on Keller's malt soup. 1 This 
preparation has been used by me with very good result. When it was dim- 
cult to prepare this food the following formula served me equally well: — 

Raw cows' milk 4 ounces 

Maltine, plain 1 teaspoonful 

Bicarb, of potassium 20 grains 

Eskav's food 2 teaspoonfuls 

Rice water 4 ounces 

Mix the above and heat slowly for three minutes until it boils. Allow 
it to boil one minute. Feed every three or four hours. If the food agrees 
well add one-half ounce of milk more every four days. The Eskay food 
should also be increased until three teaspoonfuls are given with each feeding. 
If the child vomits reduce the quantity of maltine to one-half teaspoon. 

1 Formula of Keller's malt soup. See page 170. 



PART V. 

DISEASES OF THE HEART, LIVER, SPLEEN, PANCREAS, 
PERITONEUM, AND GENITOURINARY TRACT. 



CHAPTEB I. 

IN ! RODLH TORY. 

The Heart and Fcetal Circulation. 

The circulation of the blood during the whole foetal period of ante- 
natal life is the same. From the third to the tenth month the circulation 
is known as "placental/ 3 and during the intervening months it undergoes 
no marked modificatiors. 

According to Ballantyne, 1 during the neo-fcetal period, it is true the 
circulation is that of the chorion; but by the end of it there has been a 
specialization of the circulatory function, and the blood, instead of being 
sent to the villi over a wide expanse of chorionic surface, is now directed 
solely to those found over one part of it. that, namely, which is in contact 
with the decidua serotina. the site of the developing placenta. From the 
end of the neo-fcetal period onward to the moment of birth, there is the 
circulation of the placenta. 

The essential peculiarity of the placental circulation is the sending of 
the foetal blood out of the fcetal body to a specially prepared and extra- 
corporeal organ (the placenta) for purposes of oxygenation and other les^ 
understood chemical changes. This entails simply the presence of an 
efferent vessel (or vessels) to carry the blood to the extra-corporeal organ 
and of an afferent vessel to bring it back again. 

Changes at Birth. — When the umbilical cord is ligated there is an 
interruption of the circulation through the umbilical vein and arteries, so 
that in about ten days after birth the circulation loses its fcetal type and 
assumes extra-uterine conditions. 

The following physiological changes occur : — 

(a) The conversion of the ductus arteriosus. 
The ductus venosus into fibrous cords. 

i c) The closure of the foramen ovale. 

(d) Changes in the umbilical veins and umbilical arteries, the first 
forming the round ligament of the liver, the second the true anterior liga- 
ment of the bladder and the superior vesical arteries. 



1 For those interested I 
pathology and hygiene. 



,-oulcl advise retulinj? Ballantyne's book on ante-natil 



(361) 



(62 



THE HEART AND FCETAL CIRCULATION. 



For some weeks before birth the circulation through the foramen ovale 
is slight, it being gradually obstructed by the growth of a septum which 
nearly fills the space at birth. After the first week of extra-uterine life, 
very little if any blood passes through it, although complete closure of the 
foramen often does not take place until the middle of the first year. In 
one-fourth of the autopsies Holt made upon infants under six months of 
age, minute openings at the margin of the foramen ovale were found. They 
were usually oblique, and closed by the valvular curtain so as to effectually 
obstruct the current of blood. The ductus arteriosus is first closed by a 
clot, which becomes organized and blends with the products of a proliferat- 




Fig. 110. Fig. 111. Fig. 112. 

Fig. 110. — Note the Position of the Apex Beat in a Very Young Infant; 
during the first year it is very high, between the fourth and fifth inter- 
costal spaces. It is most often in the fourth. 

Fig. 111. — The Apex Beat in a Child About 6 Years Old. It is lower 
than in an infant. Usually found at the fifth intercostal space. 

Fig. 112.— The Apex Beat in a Child About 12 Years of Age is found 
between the fifth and sixth intercostal space. 

The heavy black lines denote the area of relative dullness. The small 
shaded areas denote the area of absolute dullness. (After Unger.) 

ing arteritis. It is rarely found open after the tenth day, and by the 
twentieth it is almost invariably obliterated. 

The Heart. 1 

Size of the Heart.— The relative size of the heart is greater in children 
than in later life. It is smallest about the seventh year, 

Table No. 57. — Weight of the Heart {Boyd). 
Age. Grams. 

At birth 20.6 

One and one-half years 44.5 

Three years 60.2 

Five and one-half years 72.8 

Ten and one-half years 122.6 

Seventeen years . 233.7 

1 Heart murmurs are described on page 366. 



THE HEART. 363 

The anatomical differences in the child arc: — 

(a) A more horizontal position ol' the heart than in the adult. 

(b) The diaphragm being higher, the heart is higher in the thorax. 

(c) The ribs in a child are more horizontal than in the adult. 

(d) The liver in young children is larger than in adults, and as the 
heart is in close contacl with the liver the area of cardiac dullness merges 
into that of the liver dullness below. 

Tension. — The degree of contraction of the vascular muscles deter- 
mines the size of the artery and (to a great extent) the tension of the 
blood within it. But if the heart is acting feebly there may he so little 
blood in the arteries that even when tightly contracted they do not subject 
the blood within them to any considerable degree of tension. "To produce 
high tension, then, we need two factors: a certain degree of power in the 
heart-muscles, and contracted arteries. To produce low tension we need 
only relaxation of the arteries, and the heart may be either strong or weal'. 

"The pulse of loir tension collapses between beats, so that the artery is 
less palpable than usual or cannot be felt at all. Normally, the artery can 
just be made out between beats, and any considerable lowering of arterial 
tension makes it altogether impalpable except during the period of the 
primary wave and of the dicrotic wave, which is often very well marked 
in pulses of low tension." 

"The pulse of high tension is perceptible between beats as a distinct cord 
which can be rolled between the fingers, like one of the tendons of the 
wrist. It is also difficult to compress in most cases, but this may depend 
rather on the heart's power than on the degree of vascular tension. The 
pulse wave is usually of moderate height or low, and falls away slowly with 
little or no dicrotic wave. 

Fig. 113. — Irregular Pulse, Low Tension, from a Case of Mitral 
Regurgitation. (Original.) 

Mode of Examination of the Heart. — The ear should be used, rather 
than an instrument in listening to the heart sounds in struggling children. 
In children with eruptive fevers it is safer to use a phenendoscope. For 
this purpose the Bowles phenendoscope (Fig. 114) is highly recom- 
mended, as it has a flat attachment which can conveniently be placed in 
the axilla or to the posterior portion of the lung without raising the child 
from the "bed. These advantages are important inasmuch as we frequently 
can examine the child wdrile asleep. 



364 



THE HEART AND FCETAL CIRCULATION. 



The following aphorisms are drawn from Crandall : 

1. The apex lies higher in the chest and further to the left than in 
the adult. 




Fig. 114. — Natural Size of Bowles Stethoscope for Examining Children. 

2. The apex beat is hard to detect in the infant. In the child palpa- 
tion shows this easier than in the adult. 

3. The area of dullness is comparatively large. (There are three 
stages in infancy and childhood during which differences are noted in rela- 
tive and absolute dullness.) (See Figs. 110, 111, and 112.) 




Fig. 115. — A Convenient Stethoscope for Children. Made by Gr. Tiemann 
& Co. and by George Ermold, New York City. 



4. Murmurs are heard over comparatively large areas. A study of 
differences in the quality of the sounds and points of greatest intensity will 
help us here. 

5. The rate may be increased and the rhythm altered by slight causes. 

6. In rachitic children and in those affected by empyema or pleural 
effusions and adhesions the apex may appear in an abnormal position. 

7. Prominence of the precordia is sometimes marked. Normally the 
loudest sound is the first sound at the apex; the weakest sound is the 
second sound at the aortic cartilage. This accords with my experience, 



THE HEART. 



305 



though it docs m>( seem bo be generally recognized thai the pulmonic second 
sound is in early life stronger than the aorfic sound. 

Table No. 58. — Classification of Cardiac Diseases. 



Time of 
Occurrence. 



Intra-uterine 

existence 

or very 

early infancy. 



Extra -nterine 

existence 

(infancy or 

childhood). 



Nature of the Affection. 



Developmental 

or 
Inflammatory. 

Various motor or sensory 
phenomena unaccom- 
panied by sensible 
changes of structure. 



Organic, 



Mechanical. 



. Inflammatory. 



Miscellaneous. 



Clinical Disease. 



Various congenital affections. 



Functional diseases of the heart. 



{Dilatation, ") Alone or as accom- 
J- paniment of in- 
Hypertrophy, J flam matory change. 



T Pericarditis, acute or chronic. 
< Endocarditis, acute or chronic. 
I Myocarditis, acute or chronic. 

{Effusions (non-inflammatory). 
Granulomata. 
Neoplasms. 



CHAPTER II. 

DISEASES OF THE HEART. 

Reflex Symptoms of the Heart. 

Tachycardia. — Severe palpitation of the heart (tachycardia) fre- 
quently results from excitement or fright in children. The heart on aus- 
cultation will be found normal, and the only symptom noticeable will be 
an exaggerated pulse-rate with an increase of twenty to forty beats per 
minute. It is usually a neurotic manifestation. As a rule the prognosis 
is good. The treatment consists in removing the cause if possible. 

Bradycardia. — A slowness of the heart's action and a slow pulse-rate 
are occasionally met with in children. It may occur in health, although very 
rarely without pathological significance. I have usually seen bradycardia in 
septic cases of diphtheria at my service in the Willard Parker Hospital, and 
in the septic type of scarlet fever at the Riverside Hospital. When brady- 
cardia is seen during the course of acute infectious diseases it should be 
regarded as a very serious symptom (see chapter on "Diphtheria"). 

Points to be Noted in the Diagnosis of Diseases of the Heart. 

Heart Sounds and Murmurs. 

First Sound. — In infectious fevers there is an increase in the length 
and intensity of the first sound heard at the apex. 

In continued fevers causing degeneration of the heart muscles there 
is a shortening and weakening of the first sound heard at the apex. 

In exhaustive heart strain seen in myocarditis the first sound is feeble 
and merges into the second sound. This condition is met with in diph- 
theria, scarlet fever, and typhoid, although any disorder of the body which 
devitalizes may cause it. 

Fatty heart, emphysema, or pericardial effusion may give a feeble mitral 
first sound. 

Pulsus Paradoxus. — The heart- beats during inspiration are more fre- 
quent, but less full, than during expiration. This condition may be observed 
in healthy children during sleep. 

An irregular heart's action may occur during sleep in healthy children. 
The heart's action is frequently influenced by inspiration and expiration. 

Systolic Murmurs. — There are two murmurs possible for each orifice, 
or eight in all. Of these, four, namely, mitral systolic, mitral presystolic, 
(366) 



MURMURS. 



3(>7 



aortic systolic, ami aortic diastolic, arc most likely to occur, with a fre- 
quency aboul in the order of their enumeration. The necessary changes 
being made a like distribution applies to the right side; although a pul- 
monary lesion is almost unknown, except as a congenital affection, while 
disease of the tricuspid valve is less rare. 

Every murmur is determined by the time of its occurrence, the direc- 
tion which it takes, and the location of its greatest intensity. The blood 
is driven from the left ventricle, during systole, through the aortic orifice, 
and, meanwhile, all communication with the auricle of this side is cut off 
by a closure of the mitral valve. But should the current encounter an 
obstacle at the aortic opening in its onward course, it would be thrown into 
confusion in the aorta, from which a murmur would arise and be carried 
upward. Hence this bruit is loudest at the aortic area, systolic in rhythm, 
and extends in the direction of the carotids. 

Should the mitral valve fail to close at this time the blood would 
escape into the left auricle, as well as run through the proper channel, and 
be set in vibration by the impeding flaps at the mitral orifice. Here the 
bruit generated by this disturbance is borne with the reflux into the auricle, 
and thence to the back, and also by conduction through the apex to the 
front. Moreover, it is loudest in front and at the apex, because the heart 
is nearer the anterior than the posterior surface of the chest. Therefore, 
this murmur is most intense at the mitral area, systolic in rhythm, com- 
monly diffused to the left, and often audible near the inferior angle of the 
left scapula. 

In a similar manner during systole, the blood is being propelled by 
the right ventricle through the pulmonary aperture, and likewise the tri- 
cuspid valve is closed or very nearly so. Thus supposing that an obstruc- 
tion were to occur at the pulmonary orifice, there would be a systolic mur- 
mur, with point of maximum intensity in the pulmonary area and extension 
upward to the left, but not into the carotids. 

In the event of tricuspid insufficiency, part of the blood would flow 
back into the right auricle, and give rise to a systolic bruit, best heard in the 
tricuspid area, and spreading upward to the right. 

Anaemic Murmurs. — An anaemic murmur is always systolic in rhythm, 
loudest at the base of the heart, and often as audible in the aortic as the 
pulmonary area. With anaemia pure and simple there should be no cardiac 
hypertrophy. 

Diastolic Murmurs. — In diastole the aortic and pulmonary valves are 
closed, and the auriculo-ventricular valves open, while blood is flowing from 
the auricles to the ventricles. The vermicular contraction, styled cardiac 
systole, which was initiated in the veins and taken up by the auricles, has 
gone through the ventricles and reached the large arteries, wherein the recoil 
of the current finds a point of support at the closed semilunar cusps. 



368 DISEASES OF THE HEART. 

If the function of one or more of these cusps in the aortic valve be 
destroyed, each contraction of the artery will drive a portion of its contents 
back into the left ventricle; and the vibrations generated in this return 
stream against the disorganized valve will cause a bruit that is aortic in 
origin and diastolic in rhythm. 

Though this murmur of insufficiency is conveyed along the arteries a 
varying distance in the efflux, its main direction is backward with the reflux ; 
not so much in the line of the ventricle as down the sternum, owing to the 
close proximity of this bone to the aortic valves, and its superiority over 
the heart as a conducting medium of sound. The point of maximum in- 
tensity of this bruit is more often at the lower end of the sternum than in 
the second intercostal space. Granting that the same thing could happen 
to the pulmonary valves, a diastolic murmur would be audible in the pul- 
monary area, but with an extension downward only. 

An aortic systolic murmur is loudest in the second right intercostal 
space close to the sternum, and a diastolic bruit is heard loudest at the lower 
extremity of this bone. In some instances these murmurs are heard only 
at mid-sternum, about on a level with the third costal cartilages. In others 
they are most intense in the second, and even the third intercostal space, 
close to the left edge of the sternum. Upon the exclusion of aneurism, a 
bruit within these precincts is presumably aortic and not pulmonary, espe- 
cially if the right ventricle is unenlarged. 

Pericardial Murmurs. — A pericardial is distinguished from a pleuritic 
friction mainly by the time and locality of its occurrence. Grating in the 
pericardium obviously is limited to the precordial region,, and is regulated 
by the action of the heart. That of the pleura, is most prone to take place 
in the infra-axillary regions, where pulmonary mobility is extensive. It is 
dependent upon the respiratory movements. 

Venous Murmurs. — In quality venous murmurs are blowing, cooing, 
and sometimes musical; and from the frequent resemblance of the noise 
to that of a humming-top, it has been denominated venous hum. 

It is usually most distinct at the lower third of the external jugular 
reins, and more distinct in the right than in the left side. It is always con- 
tinuous in rhythm, but the intensity is often remittent because of the 
periodical acceleration of the stream by the action of the heart. The direc- 
tion is downward and inward along the subclavian and right innominate 
veins, so that it is now and then audible through the aortic area, and can be 
separated with a little care from the aortic sounds as well as from the 
respiratory murmur. When there is a question as to whether or not a given 
bruit is venous or arterial, pressure upon the vein above the stethoscope will 
stop the downward current and silence the venous hum. 



PULMON \KY SI ENOSIS. 

Cerebral Blowing.— A blowing, systolic murmur, of variable intensity, 
is frequently heard over the anterior fontanel and Bometimes over the 
carotids of children, between the ages of three months and six years. 1 

Pulmonary Stenosis (Congenital Eeart Lesion: Blue Baby). 

A. N. IT., born May 7. 1904, was first seen by me when seven months old, in 
consultation with Dr. E. 1). Lederman. 

/'■ ily History — It was the third child born with natural labor. The mother 
has had one still-birth and one miscarriage. Has one child 5 years old in good health 




-LOUD SYSTOLIC 
MURMUR, 



SYSTOLIC MURMUR. 

(very forcible thrill 
transmitted on palpation.) 



Dotted inner line denotes 
normal area of heart. Shaded 
line around heart — area of 
cardiac (Inline-- on percussion. 



Pier. Hfi. — Case of Pulmonary Stenosis — Congenital — Blue Baby. (Original.) 






with no evidence of heart trouble. Both father and mother are in excellent health, 
and there is no evidence of heart or lung trouble, and no specific disease on either 
side. This child has been cyanotic. The toe nails and finger nails show typical 
clubbing and also blueness. On the slightest exertion the infant's skin assumes a 
very dark blue color. Dyspnoea is also present. The cutaneous circulation is very 
poor and the nurse informed me that for one-half hour after a tub bath there is an 
increased evidence of cyanosis. 

A loud blowing systolic murmur could be made out in the second intercostal 
space. Tbere was also a weakness of the pulmonary second sound. The area of 
dullness was increased so that a right-sided hypertrophy undoubtedly existed. The 
murmur was not transmitted to the vessels of the neck. 

The infant was breast-fed by its mother for four and one-half months. There 
has been a tendency to constipation. The stool has been green and contained white 



i I am indebted to S. S. Burt & E. Le Fevre for some points in the above article. 

24 



370 DISEASES OF THE HEART. 

curds at times. During the last few months the feeding consisted of equal parts of 
barley water and milk. When seen again the appetite was poor. The tongue 
slightly coated. The general condition one of restlessness by day and insomnia 
by night. The infant was very sensitive to cold and had a diffuse bronchitis 
associated with acute rhinitis. I ordered: — 

R Raw milk 12 ounces 

Rice water 24 ounces 

Granulated sugar 6 drachms 

Lime water 6 drachms 

Peptogenic milk powder 2 measures 

Divide in six bottles. Feed every 3 X 2 hours. 

As the food agreed very well, I ordered 1 ounce more of milk to the total 
quantity every second day until the infant received full milk undiluted. 
I ordered to relieve the dyspnoea and regulate the heart: — 

B Sodium iodide 15 grains 

Sparteine sulphate 3 grains 

Elix. lactopeptin 2 ounces 

Half-teaspoonful three times a day. 

The progress of the case was excellent. When first seen by me there was no 
evidence of dentition. At the ninth month the child had two teeth and showed 
signs of general development. 

Prognosis. — As a rule the outcome of these eases is bad. although I 
have known a child with a pulmonary stenosis for the last twelve years. 
He is now 18 years old and is able to do light work. These cases have a tend- 
ency to pulmonary disease, and are especially prone to develop tubercu- 
losis. 

Persistence of the Ductus Arteriosus Botalli. 

During the first four weeks after the birth of an infant, the ductus 
arteriosus is closed by an overgrowth of the cells in its inner wall. When 
abnormal conditions exist, such as septic infection of the new-born with 
thrombi, a breaking down of the cell growth takes place and results in the 
duct remaining patent. This may also result from defective respiration 
and an anomalous pulmonary circulation. 

The clinical symptoms of the patency of the ductus arteriosus are 
rapid hypertrophy and dilatation of the right ventricle, with co-existing 
dilatation of the pulmonary artery. There is also an increased area of 
cardiac dullness. Loud systolic murmurs are heard all over the chest, and 
a thrill of the anterior chest wall can be felt. Protrusion of the upper part 
of the sternum — dyspnoea rarely — cyanosis and a deathly pallor. 

Gerhardt states that dullness is found at the border of the second rib, 
in which region the systolic pulsation of the pulmonary artery can be felt. 



ENDO< ARDITIS. 



:;:i 



M. <■'.. tour months old. Was two weeks prematurely born. She was tin- 
second child. The first child died of diphtheria; it was also prematurely born, and 
died when its mother was tour months pregnant with the present baby. The mother 
had a normal pregnancy, but was greatly troubled with headaches and dizziness, and 

suffered mentally over the lo^s of the first child. 

The Bab}/. — When the baby was six weeks old the mother first noticed that it 
breathed with difficulty. It had been vomiting continuously. Diarrhoea has existed 
for ten weeks. There is an occasional cough. Since two weeks the baby appears 
colicky and cries with apparent pain. 

Stat. Pnrs. — A pale, very anaemic looking child, with large fontanel, somewhat 
depressed, the size of a silver quarter. 

The Eyes. — There was a slight exophthalmus. The nose., somewhat depressed. 
Slight coryza. 

The Heart. — The area of dullness extends from the right side to the left border 
of the sternum., corresponding to the lower border of the third rib. The apex is 



FRONT. 



BACK. 




Fig. 117 



SYSTOLIC 

MURMUR. 

HEARD 

FOSTER I CELT' 



-Child with Persistence of the Ductus Arteriosus Botalli 
murmur audible — blowing presystolic. (Original.) 




X, Loud 



at the lower border of the fifth rib. immediately under the mamilla. The heart is 
somewhat enlarged toward the left side. 

Auscultation. — A loud presystolic murmur is heard over the whole area of the 
heart. There is marked abdominal respiration. The lungs are normal in percussion. 
Moist rales can be heard over both lungs. 

The Abdomen. — The abdomen is distended and is tympanitic on percussion. It 
feels doughy on palpation. There is no cyanosis of the fingers or toes. There is 
a mild dyspnoea. The adipose tissue is not very apparent. There is marked 
prominence of the subcutaneous veins of the scalp. 

The clinical history of the mother did not give any evidence of miscarriage. 
no syphilis, and no family tuberculosis. 



Endocarditis. 

This disease is of frequent occurrence during infancy and childhood. 
Congenital endocarditis has frequently been reported, so that it is assumed 



it must have existed during fcetal life. 



372 DISEASES OF THE HEART. 

Etiology. — Gerhardt and Bednar believe that the disease occurs quite 
frequently in young children, although the greatest frequency is noted 
between the sixth and the twelfth years. Acute rheumatism is very fre- 
quently followed by endocarditis. Chorea is also frequently accompanied 
by endocardial disease. Scarlet fever, measles, variola, varicella, diph- 
theria, typhoid, and tuberculosis, according to Eeimer, are frequently fol- 
lowed by or associated with endocarditis. When endocarditis follows pneu- 
monia, pleurisy, or bronchitis, it is due to the invasion of pathogenic bac- 
teria. These are the staphylococcus, according to Frankel and Sanger, and 
the pneumococcus, according to Netter and Weichselbaum. The germs 
enter the deeper portion of the pericardium through the epithelium, causing 
inflammatory conditions. It is quite likely that endocarditis is caused by 
such invasion in acute joint inflammations, in phlegmonous periostitis, 
lymphangitis, pericarditis, myo-carditis, and puerperal infections. Bouchut 
has reported cases of endocarditis following erythema nodosum and hered- 
itary syphilis. Von Dusch has reported endocarditis following extensive 
burns of the hand. 

Pathology. — The lesions occur most frequently on the valves of the 
heart. The valves on the left side of the heart are most frequently affected, 
hence, the mitral is the seat of the lesions more often than the aortic valve. 
In studying a series of these cases given by Steffen, we find that about 4 
per cent, show lesions in the aortic valve. 

The pathological changes consist -in hyperemia, swelling, and an 
infiltration of normal cells or new connective tissue cells having a grayish- 
white color. There is a breaking down of the epithelium besides wart-like 
excrescences called vegetations are formed on the free border of the thick- 
ened valves (endocarditis verrucosa). The result caused by the last-named 
condition is that the vegetations prevent a proper closing of the valves, 
which latter results in insufficiency and stenosis. Fibrinous deposits are 
frequently noted on the valves, and on being carried with the circulation 
may lodge in the cerebral arteries, causing either emboli or infarctions, 
according to Virchow. The last-named condition is exceptional in acute 
endocarditis. 

Symptoms. — Endocarditis, whether primary or secondary, begins with 
fever. Not infrequently the temperature rises to 102°, sometimes 103° 
F., and there is a corresponding increase in the pulse-rate. The pulse is 
rapid, irregular, and of low tension. Cyanosis is sometimes present, espe- 
cially so if myocarditis accompanies the attack. Sometimes a child will 
develop endocarditis without any special symptoms being present. Not 
until the heart is examined will the condition be diagnosed. Thus an 
important rule which has been previously mentioned is the necessity of 
always listening to the heart when a diagnosis is uncertain. Frequently 
a few days will pass without specific symptoms being recognized. A child 



ENDOCARDITIS. 373 

will show evidence of malaise and suddenly the characteristic blowing sys- 
tolic murmur will be heard at the apex. The murmur is usually trans- 
mitted to the left and can also be heard behind. It is frequently accom- 
panied by the thrill and by an accentuated pulmonic second sound. When 
dilatation results there will be a cardiac insufficiency. The murmur may 
gradually increase in intensity and in the same manner it may diminish 
until it is inaudible. When fever suddenly appears during the course of 
an attack of chorea, endocarditis should be suspected. In some cases 
dyspnoea may be present. 

The diagnosis is frequently obscure because a child will have no symp- 
toms of a definite nature. If, however, we are patient and carefully ex- 
amine the heart, we may be rewarded by making the diagnosis. It is in> 
portant to examine all the organs of the body before making a positive 
diagnosis, if obscure or no cardiac symptoms exist. 

Inspection will always show a rapid and diffuse apex-beat. 

Palpation will confirm this observation and may reveal a strong but 
irregular heart action. 

Percussion is usually negative. 

Physical signs are due to (a) insufficiency, (b) roughening, (c) ste- 
nosis, depending on changes in the valves. The character of the murmur 
depends on the valve involved and the lesion of the valve. In mitral regur- 
gitation we have a systolic murmur with greatest intensity over the apex. It 
is usually transmitted to the side, and also heard behind the sternum. 

In mitral stenosis we have a presystolic murmur with the greatest 
intensity over the mitral area. 

In aortic regurgitation we have a diastolic murmur with the greatest 
intensity over the aortic valve, and, transmitted down the sternum. 

In aortic roughening we have a systolic murmur with the greatest 
intensity over the aortic valve. Distinct murmurs can be heard at the 
valves of the right side. 

An embolism in some portion of the body is frequently the sign of a 
heart lesion. If the embolus reaches the brain, hasmiplegia is the usual 
result. If it reaches the lungs severe dyspnoea may result. An embolus 
in the mesentery may result in diarrhoea. If in the kidneys, hematuria may 
result. When it reaches the limbs it means an obstructed circulation. 

Prognosis and Course. — Endocarditis if carefully managed with rest 
and strengthening diet will improve. I have seen children with endocardial 
murmurs improve after a few weeks, when put to bed amid quiet surround- 
ings. As a rule the prognosis is bad and the course of the disease tends 
to become chronic. In giving an opinion as to the outcome of a case of 
valvular lesion, we must remember that we are dealing with a damaged 
heart, and that months or years may pass before recovery can take place. 
A fatal outcome will be the result of carelessness or mismanagement. 



374 DISEASES OF THE HEART. 

Treatment. — Nothing will do more good than absolute rest in bed. 
Small doses of codein or Dover's powder act very well. If endocarditis 
accompanies or follows rheumatism then the salicylates should be given. 
An ice-bag over the heart is frequently useful. If the pulse is very rapid 
or the heart's action is feeble, then digitalis or strophanthus should be 
given. 

The tincture or an infusion of digitalis made from English leaves is 
the best. A point to remember is that digitalis has frequently an accu- 
mulative effect so that the pulse must be carefully guarded during its 
administration. When this is the case the administration of the tincture 
of strophanthus will be found very serviceable. In some children digitalis 
will be badly borne owing to its irritant action on the gastric mucous 
membrane. In such cases sparteine or strophanthus should be prescribed. 

Adrenalin chloride solution taken internally increases the blood pres- 
sure, stimulates the heart, and retards the pulse-rate. It is better than 
digitalis, as it does not irritate the gastric mucous membrane, and it is 
non-cumulative. 

Ifc Sol. adrenalin chloride 1-1000 

Infants of 1 year, 1-5000, made with normal saline solution. 
Dose: Five to 10 drops, three times a day, gradually increased until effect 
on pulse is manifested. 

In some cases marked benefit will follow the use of iodide of sodium 
in doses of 1 to 5 grains, according to age. The iodides seem to steady the 
heart's action. I have found excellent results following their use. 

Malignant Endo carditis. 

This is commonly called ulcerative endocarditis. It is a rare condition 
in childhood. Harris reports a case in a child 4 years old. The type of 
the disease is similar to that noted in adults. This condition is rarely 
primary. It occurs with scarlet fever, erysipelas, pneumonia, rheumatism, 
and septicaemia, in which bacterial invasions of streptococci or pneumococci 
occur. These germs are found in the endocardium. 

Pathology. — Vegetations usually occur with ulcerations in the cavities 
and on the valves. Suppuration of the deeper tissues with abscess forma- 
tion is frequently noted. Osier states that the different parts of the heart 
are affected in the following manner : mitral valve, aortic, mitral and aortic 
combined, tricuspid and pulmonic valves, and the cardiac wall. The sec- 
ondary lesions of malignant endocarditis are due to emboli. These are 
most frequent in the spleen and kidney, next in the brain, intestines, and 
skin, and, if the right side of the heart is diseased, in the lungs. These 
emboli lead to the formation of red or white infarctions, to haemorrhages, 



PERICARDITIS. 375 

or to multiple abscesses in the various organs and tissues in which they 
Lodge. 

Symptoms. — It is extremely difficult to diagnose malignant endocar- 
ditis. The presence of symptoms of pyaemia or septicaemia, associated with 
a heart murmur, usually renders the diagnosis positive. There is a remit- 
tent type of fever, occasionally delirium and extreme prostration. The 
cerebral symptoms frequently suggest meningitis. There is sometimes a 
faint mitral regurgitant murmur. Not infrequently it is entirely absent. 
The spleen is usually enlarged. Hemiplegia as well as hematuria and 
rapid swelling of the spleen, or possibly symptoms of pneumonia, are fre- 
quently the result of emboli. 

Diagnosis. — This is at times extremely difficult. An examination of 
the blood for plasmodia will usually be the means of excluding malaria if 
the same is suspected. 

Prognosis and Course. — The rapidity of the onset and the malignancy 
of the disease go hand in hand. The outcome is usually fatal. 

Treatment. — In addition to rest and a supporting, stimulating diet, 
nothing but relief of individual symptoms by routine treatment can be 
given. 

Pericarditis. 1 

This disease may exist with or without myocarditis or endocardial 
involvement. Large effusions occur more readily in children than in 
adults. 

Etiology and Causes. — Eheumatism is the most frequent cause of 
pericarditis. Apparent mild forms of rheumatism, such as are frequently 
called "growing pains' 7 by the laity, are quite often complicated by peri- 
carditis. In this manner the existence of the rheumatism preceding the 
pericarditis is strikingly brought out. 

Pericarditis is rarely a primary condition. Septic infection of the 
umbilicus occasionally causes this condition. 

Tuberculosis, scarlet fever, diphtheria, measles, typhoid, and influ- 
enza frequently precede a pericarditis. 

Baginsky found purulent pericarditis associated with phlegmonous 
erysipelas, grave forms of angina, caries of the ribs, fibrinous pneumonia, 
broneho-pneumonia, gastro-enteritis, furunculosis, phlegmon of the throat, 
and empyema. It not infrequently follows kidney disease and scurvy. 

Pericarditis is met with at any age. It has been met with in the foetus, 
according to Billard, Bednar, Hiiter. and Steffen. 

Bacteriology. — We most frequentlv meet with a staphylococcus aureus 
or streptococci, bacterium coli, and the diplococcus pneumoniae. 



1 The anatomical outlines are illustrated and described in the article on "The 
Heart and Circulation." See "Introductory." Part V. 



376 DISEASES OF THE HEART. 

Pathology. — Pericarditis may be divided into : — ■ 

(a) Plastic pericarditis. 

(b) Pericarditis with serous or purulent effusion. 

(c) Adherent pericarditis. 

Any of the above-mentioned varieties consists of an inflammatory 
affection involving the serous covering of the heart and its reflection on 
the inner surface of the pericardial sac. 

Symptoms and Diagnosis. — The acute condition begins with fever 
reaching as high as 104° F. in some instances. Associated with this there 
is pain in th^ precordial region. Dyspnoea is present. There may be left 
pleurothotonos (a bending of the body to one side). The pulse is usually 
rapid. When there is effusion the child will complain of either very sharp 
pains or merely a sense of heaviness and discomfort. Syncope, singultus, 
and severe manifestations are present in the severer types of the disease. 
Not infrequently there may be delirium, twitching, and cerebral symptoms 
simulating meningitis. When effusions are abundant, cyanosis frequently 
occurs. 

The physical signs resemble those of adults. In dry pericarditis a 
double friction sound is heard over the prsecordial space. The area is small 
and near the base of the heart. The sound is not transmitted and is inde- 
pendent of the respiratory movement. If effusion takes place the apex- 
beat will be found displaced, sometimes upward and outward or indistinct ; 
in some instances it cannot be found at all. There may be bulging of the 
chest wall. The intercostal spaces become very prominent. On palpation 
there is an absence of vocal fremitus over an area usually occupied by the 
lung. 

Percussion gives an area of marked dullness or flatness of triangular 
shape, the base being below and the apex above. The normal area of car- 
diac dullness is increased in all directions, and this dullness extends beyond 
the limits of the heart. On auscultation the heart sounds are feeble and 
distant. Friction sounds disappear as serum is poured out, and reappear 
as it is absorbed. Endocardial murmurs may also be present. In infants 
physical signs are often entirely wanting, or the normal sounds may be 
feeble, distant, or absent. 

The usual duration of acute pericarditis is from one to three weeks. 
The ordinary dry form, with the resulting adhesions, may be followed by 
a subacute or chronic form of the disease. In the sero-nbrinous form the 
serum is usually absorbed quite promptly, and only adhesions are left or 
a chronic inflammation follows, with exacerbations in each recurrence of 
rheumatism. In the purulent form of the disease in young children, death 
is the most frequent termination. If the pus is evacuated or spontaneous 
opening takes place, there may be recovery, but always with more or less 
extensive adhesions remaining. 



CHRONIC PERICARDITIS Willi ADHESIONS. 



377 



Prognosis. — -The prognosis should always be looked upon as very grave. 
Steffen states that out of 35 cases only 6 recovered. When this disease 
follows pyaemia, or when it is a sequela to the acute infectious diseases, the 
prognosis is very had. When it is associated with rheumatism the ultimate 
results, by reason of adhesions and dilatation, are usually very serious. 

Treatment. — Children affected with acute pericarditis should be put 
to bed and kept quiet. An ice-bag placed over the heart and small doses 
of opium or Dover's powder seem to steady the heart's action. The value 
of aconite in this disease must not be forgotten, especially when we have 
excessive heart's action. Very bad effects have been noted by me when 
either pilocarpine or jaborandi was given. The specific effect of salicylate 
of soda, salol, or salophen must be remembered if due to rheumatism. 

Aspiration of (lie Pericardium. — When symptoms of collapse, cyanosis, 
irregular pulse, and severe dyspnoea are present, then aspiration may do 
good. If, on aspiration, we find pus present, an incision should be made 
and drainage should be used as Ave would in a case of empyema. The proper 
place to puncture the pericardium is a point a little to the left of the 
border of the sternum in the fifth intercostal space, the needle being directed 
upward and outward. It must be remembered that by this means only 
can relief be expected. Keating states that "of 18 cases punctured only 4 
recovered." 

Chronic Pericarditis with Adhesions. 

When children suffer with repeated attacks of rheumatism complicated 
by pericarditis, a chronic pericarditis frequently remains. Holt describes 
a case of a child sixteen months old, in which the pericardial sac was com- 
pletely obliterated. Associated with this condition we frequently have 
chronic myocarditis, hypertrophy, dilatation, and valvular lesions, so that 
no portion of the heart muscle or its lining membrane is normal. 

Symptoms and Diagnosis. — According to Broadbent, there is a con- 
traction seen behind in the infra-scapular region, sometimes on the left, 
sometimes on the right, side in the region of the eleventh or twelfth rib. 
Anteriorly we have the characteristic sign. It is a systolic retraction, 
of the chest at or near the apex of the heart, sometimes at the tip of the 
sternum. This is due to the external pericardial adhesions, and is often 
better made out by palpation than by inspection. After the systole there 
is a rapid rebound, known as the diastolic shod-. A collapse of the cervical 
veins during the diastole of the heart, known as Friedreich's sign, is also 
seen. Sometimes we see an inspiratory swelling (Kussmaul). In addition 
the pulsus paradoxus is significant of the presence of pericardial adhesions, 
or rather of the dilatation that succeeds the adhesions. The pulse is small 
and feeble during inspiration, assuming greater strength during the period 
of expiration. 



378 DISEASES OF THE HEART. 

Percussion shows an increase in the cardiac dullness in all directions. 
The position of the apex and the percussion outline of the heart do not 
change with the posture of the patient, and the cardiac dullness is but 
little affected by full inspiration, A systolic murmur is often present. 
The diagnosis of adherent pericardium always presents difficulties, but it 
can be made with tolerable certainty in a considerable portion of the cases. 
On account of the enlargement of the heart and the frequency of murmurs, 
it is usually mistaken for valvular disease. The lesion is a permanent one 
and tends to increase. If a child suffers with valvulitis and the symptoms 
do not yield to digitalis, then adhesive pericarditis should be suspected. 

Treatment. — There is no known method of treatment which will mod- 
ify or improve this condition, excepting a supporting diet with absolute 
rest in bed and general restorative treatment. It is very important to 
watch the emunctories and stimulate them if their action is sluggish. 

Tuberculosis of the Pericardium. 

This condition is rarely met with as a primary process; it is chiefly met 
with as a secondary process. It usually partakes of a general tuberculous 
process in which all the organs of the body participate, among them the 
pericardium. 

Diagnosis. — The diagnosis of this condition depends on the symptoms 
which usually accompany pericarditis. The tubercular nature of the dis- 
ease must depend on the presence of tubercle bacilli in the exudation, 
although Inger denies the possibility of making such a diagnosis. Most 
probably a positive diagnosis will be made as in many obscure lesions — 
post-mortem. 

The treatment is the same as that previously described in the article 
on "Acute Pericarditis." 

Hydropericardioi. 

Occasionally we meet with cases in which the symptoms of dyspnoea 
and cyanosis rapidly develop. Steffen maintains that such alarming symp- 
toms frequently occur within a few hours, and that the same will some- 
times disappear under appropriate treatment in a few days. 

Pathology. — A transudation of serous liquid in the pericardium with- 
out inflammatory process is usually a secondary condition in which drop- 
sical effusions appear. Usually hydremic conditions of the blood, such as 
the result of long-continued fevers in infectious diseases, tuberculosis 
among others, predispose to this condition. 

The prognosis depends upon the cause leading to this condition. 

The treatment is chiefly restorative, and will depend on maintaining 
the strength of the child by careful diet and hygiene. 






MYOCAKDITI& 



An inflammatory conditioD LnYolving the heart muscles- may be either 
acute or chronic. It occurs as (a) parenchymal -. ~t it ial. 

n has reported 33 cases. It is met with more often in boys than in 
girls. 

This affection is wry frequently seen during the convalescent 
diphtheria. J: - Is a frequent complication of scarlet fever. I have met 
this complication in the wards of the Willard Parker and Riverside Hos- 
pitals. 

Causes. — When it is primary it is due either to rheumatism, congenital 
syphilis, or tuberculosis Secondary, it is due to endocarditis, pericarditis, 
toxins from infectious fevers, or phosphoric, arsenic, or lead poisoning. 
Traumatism has also caused myocarditis. 

Pathology. — The heart muscles appear pale, soft, and friable. The 
whole heart is not always affected : certain portions may show evidenc - 
degeneration and fatty infiltration, while another portion may be normal. 
The myocardium is very susceptible to the toxins of infectious dis^ - 
This is especially true when diphtheria and scarlet fever have existed prior 
to the heart lesioi s. 

Symptoms. — The pulse is very feeble and slow : in some cases irregular ; 
in other cases regular. Sometimes the poise-rate is increased. The ex- 
tremities are usually cold, the surface of the skin cool. In some cases there 
is a slight rise of temperature. 100° to 101° F. Other cases show a sub- 
normal rectal temperature of 96° to .98° F. It is very evident that the 
toxins of the infectious diseases inhibit the proper action of the thermic 
centers. I have seen distinct vasomotor disturbances, such as unilateral 
flushing, affecting one cheek or the lobe of one ear. The child shows a 
marked general depression. There is a general devitalization noticeable: 
also marked apathy. The child appears listless and prefers to rest. 

The Heart. — There is an irregular, very rapid heart's action. The 
heart sounds are very indistinct. When the above symptoms occur during 
the course of infectious diseases, myocarditis should be suspected. Some- 
times there is faintness. severe dyspnoea, and cyanosis. Not infrequently 
there is albumin in the urine. Dilatation and hypertrophy sometimes occur 
without showing distinct symptoms. The ratio of the pulse and respiration 
will be disarranged. 

Diagnosis. — In some cases this is very difficult to make. The presence 
of a slow pulse and muffled heart sounds during the beginning or during the 
convalescence of acute infectious dis - - should always lead to the sus- 

n of myocarditis. A slow pulse in itself should always be looked upon 
as ominous. 



DISEASES OF THE HEART. 

Frequently a diagnosis of myocarditis is made at tlie autopsy when 
no positive symptoms of the condition were present during life. 

Prognosis. — The prognosis is certainly not good. Earely do we find 
cases of myocarditis recover. This is especially true when myocarditis com- 
plicates the acute infectious diseases and the child is in a devitalized 
condition. 

Treatment. — Excitement or exertion may cause sudden death. The 
child requires absolute rest. It should be put to bed in a recumbent posi- 
tion. High saline injections at a temperature of 115 c to 120° F.. using 
several quarts of salt water, can be tried two or three times a day. The 
diffusible effect of the hot saline, and consequently the tendency to eliminate 
toxins through the kidney, should serve as a valuable therapeutic adjunct. 
Life can certainly be prolonged by this measure; if it is cautiously done, 
so as not to exert the child's heart, the result will be apparent very soon. 

Another diffusible stimulant, which has served me very well is the 
injection of hot water to which several grains of carbonate of ammonia 
have been added. In some cases of severe cardiac depression I have seen 
good result* from the injection of : — 

R Sp. amnion, aromatic 1 - 2 drachm 

Hot water 1 quart 

Inject through a rectal tube into the colon, at a temperature of 110° to 115- F.. 
once in six hours, alternating with the hot saline. 

In syphilis or tuberculous conditions the treatment should be specific. 
When evidences of bean: failure exist, strychnine, caffein. whisky, aromatic- 
spirits of ammonia, and nitroglycerine may be used. Spartein in small 
loses «- M grain every hour) may be given. The value of concentrated 
food is greater in this condition than in any other. 

Feeding. — Xo drug will give as much strength to the body as food. 
Food should be given very frequently in small quantities. A cup of con- 
centrated chicken broth or beef broth should be given, and two hours later 
the white of two or three raw eggs with sweetened coffee. Milk punch, 
cocoa, chocolate, or strained oatmeal gruel may be given. One of the above 
foods may be given every two hours. Several ounces may be given at each 
feeding. The outcome of the case depends upon strengthening the heart. 
My plan has been to give the strychnine in the food. Drugs have a more 
diffusible effect and seem to enter the circulation better when combined 
with hot food. If for any reason the stomach is sensitive and does not 
retain food, rectal feeding with peptonized milk may be necessary along 
with the hot salines previously mentioned. 



CHAPTEB III. 
diseases i v iii k liver. 

The Liter. 

The liver in nurslings is relatively larger than in adults. To examine 
the liver place the child on its hack with the legs slightly flexed toward the 
abdomen. Have the child, if possible, breathe with regularity. 

Position cf Liver. — Dullness can be made out from the fifth inter- 
costal space in the mammary line to about one inch below the border of 
the ribs. In the axillary line it reaches from the seventh intercostal, and 
posteriorly a dullness is made out at the ninth intercostal space. It extends 
downward and can best be made out by palpating. 

Birch-Hirschfeld found the average weight of the liver in the new- 
born infant about four and one-half ounces i 127 grams 

Steffen, who has devoted considerable attention to the liver, states 
the left lobe is relatively larger in the child than in the adult. 

Bile. 

The quantity of bile in the gall-bladder is very small. It is of a golden- 
yellow color, and has a neutral reaction. Its specific gravity varies from 
1014 t 1053. A line to Baginsky, the bile in nurslings contains or- 
ganic salts — eholesterin and lecithin — fat. and various acids in less pro- 
portion than in adults. Baginsky wa* able to demonstrate the pr- 
of glycocholic acid. The presence of a much less quantity- of bile-acids in 
the infant is a beneficial physiological condition. It is a well-known fact 
that these acids inhibit the digestive action of the pepsin and of the pan- 
creatic juice. Another point is that the absence of a bile-acid prevent- - 
assimilation of large quantities of fat. as it is impossi to split up the 
fat into fatty acid and glycerine. Thus, fermentative processes are much 
more frequent in nurslings and appear with greater intensity than in the 
adult, because of the biliary acids. The amylacea and all substances con- 
taining flour are — owing to the above-described condition of the pancreatic- 
juice and the bile — not fit substances to give the infant, especially during 
its first three months of life, although very small quantities can be digt 
and after the fourth month are not only digested, but also absorbed. 

Baginsky and Sommerfeld found large quantities of mucin in the 
bile. 

Jaundice ( Icterus) .* 

There are two forms of jaundice met with in children: first, hepato- 
genic: second, hematogenic. The most common form seen in children 



- Icterus neonatorum is described in Part II. "Diseases f the New Born." 

3 



382 DISEASES OF THE LIVER. 

is a catarrhal jaundice. This is due to an extension of the catarrhal process 
from the stomach to the duodenum, causing catarrh of the bile ducts. | See 
chapter on "Gastro-duodenitis." | In the hepatogenic form, there is an 
obstruction to the flow of bile into the bowel. It is also called obstructive 
jaundice. 

In the hematogenic form there is no obstruction to the flow of bile, 
but the jaundice is due to blood conditions. TTe find jaundice in sepsis. 
in malaria, and in typhoidal conditions. Mechanical obstructions, such as 
round worms entering the common duct, have been reported, but they are 
rarities. 

Acute Coxgestiox or the Liver. 

In literature very little light is shed on this condition. Some author? 
state that malaria and other poisons, particularly phosphorus, may cause 
this condition. I believe that acute congestion of the liver is frequently 
associated with acute gastric catarrh. It is also no doubt one of the factors 
on which intestinal indigestion hinges. The symptoms are mainly those 
of enlargement which can be made out by palpation and functional de- 
rangement such as will be considered in the next article. 



c 



FUXCTIOXAL DISORDERS OE THE LlVER. 

Functional Derangement. — This very common condition is character- 
ized by either a total absence or a diminution in the quantity of bile secreted. 
This functional disorder usually causes very dry, grayish, or whitish, "clay- 
colored" stools; also flatulence. The urine is of a very dark reddish or 
brownish color. Frequently the skin and conjunctival mucous membrane 
are pigmented. The temperature may reach 101° F. ; rarely higher than 
103° F. If after rest, proper diet, and hepatic stimulation the fever per- 
sists, then the possibility of abscess in the gall-bladder should be remem- 
bered. 

Treatment. — Calomel, podophyllin. or elaterin in small doses. The 
salines and phosphate of soda in 5- or 10- grain doses can be given. Diluted 
hydrochloric acid or diluted nitro-muriatic acid, in 1-drop doses, is a good 
bile stimulant. In some cases a gentle faradic current and massage may 
do good. A cold spray over the liver will also tone the same. Large quan- 
tities of liquids will sometimes aid in relieving functional disturbance of 
the liver. 

Displacement of the Liver. 

The liver may be displaced downward when the ribs are contracted in 
size. This condition is best noted in rickets. The liver may also be dis- 
placed by pleural effusions. It is found much lower in diseases wherein 
emaciation takes place, such as in marasmic or tubercular manifestations. 
In these latter conditions relaxation of the abdominal walls permits the 
liver to occupy a position much lower than normal. 



AMYLOID DEGENERATION. 



383 



Displacement Due to Diseases of the Adjacent Organs. — The liver is 
sometimes displaced by tumors arising in the right pelvic region, chiefly 
from swelling associated with the right kidney. Jn a ease of mine (see 
chapter on "Pyelitis 55 ) the kidney pushed the liver upward and to the left. 
The liver returned to its normal position after the diseased kidney was 
removed. 

Several years ago, at the Kaiser and Kaiserin Friedrich Children's Hospital of 
Berlin, I saw a case of a child having a supposed tumor involving the liver. While 
all believed that the swelling was associated with the liver, after the abdomen was 
opened it was found that the kidney was the seat of the trouble and that the liver 
was unaffected. 

Descended Liver. 

Eowland G. Freeman, in studying a series of 496 autopsies in children, 
states that he has met, not very rarely, with descended liver. These en- 
larged livers were found in children suffering with tuberculosis and lobar 
pneumonia. In his cases the liver had slipped down the right side of the 
abdomen. 

Amyloid Degeneration (Waxy Liver). 

This is an extremely rare condition. Freeman mentions but two cases 
in his large post-mortem experience, one case associated with tuberculous 
disease of the vertebrae and psoas abscess, and the other case in a child 
suffering from progressive anaemia. The liver and kidneys were waxy in 
both cases. 

Experimentally, amyloid degeneration has been produced by the action 
of the toxins of the staphylococcus pyogenes aureus. 

Symptoms. — Special symptoms which could be called those specifically 
due to this condition cannot be described. The symptoms of the disease 
associated with amyloid degeneration are present on palpation. The liver is 
enlarged, the surface very smooth and hard, without tenderness. The 
spleen is also enlarged. Dropsy is usually present. The latter symptom 
must not necessarily be due to the kidney, but may result from pressure 
of the swollen liver upon the vena cava. When this disease is associated 
with syphilis then symptoms of the latter disease may also be found. 

The prognosis is usually bad. 

Treatment. — This depends on the symptoms, which require urgent 
management. Syphilis, when present, requires anti-syphilitic treatment. 
The outcome of the case depends on restorative treatment, including nutri- 
tion. 

Fatty Liver. 

Fatty degeneration of the liver is very frequently noted in children. 
Wollstein has found 201 cases of fatty liver in 345 consecutive autopsies. 
Freeman and Long studied a series of 296 autopsies at the Foundling Hos- 



384 DISEASES OF THE LIVER. 

pital, and found 202, or about 68 per cent., fatty livers. This disease is 
not as frequently found associated with wasting diseases as is claimed. 

The following classification of causes or conditions with which fatty 
liver is associated is given by C. Oddo, in Granchers Maladie de 
VEnfance : — 

1. Intoxications: Phosphorus, alcohol. 

2. (a) Infections, acute: typhoid fever, measles, scarlet fever, small- 
pox, and diphtheria, bronchopneumonia, acute general tuberculosis, and 
diarrhoea, (b) Infections, chronic: chronic tuberculosis, hereditary syph- 
ilis. 

3. Maladies of nutrition: chronic gastro-enteritis, rachitis. 

4. Fatty liver associated with the hepatic lesions. 

Cirrhosis of the Liver (Interstitial Hepatitis). 

Two varieties of cirrhotic liver are seen in children; they are: (a) 
atrophic, (b) hypertrophic. This condition is caused by the same factors 
that produce cirrhosis in the adult. The two most important factors that 
produce this condition are syphilis and the excessive use of alcohol. Freeman 
reports two cases in neither of which alcohol was the cause of the con- 
dition, nor was any acute disease reported prior to the cirrhosis. 

Symptoms. — Digestive disturbances, such as fullness in the abdomen, 
constipation, or diarrhoea exist. The temperature is irregular. As a rule 
the liver is not enlarged. 

Diagnosis. — This is sometimes extremely difficult and can only be 
determined positively by a post-mortem. 

Prognosis. — The prognosis depends on the cause. If due to syphilis, 
the prognosis is fair ; if due to alcohol, then it is grave. 

Treatment. — The treatment of the case depends on the symptoms 

presented. 

Focal Necrosis. 

This is usually found associated with infectious diseases. It has been 
observed resulting from the toxin of diphtheria and measles. Freeman 
found focal necrosis in 4 cases out of 14 consecutive autopsies on measles 
cases. 

Summary. — "1. Descent of the liver down the right side of the abdo- 
men, so that the right lobe reaches below the crest of the ilium, occurs oc- 
casionally in infants, and particularly in those in whom the liver is 
enlarged. 

"2. Fatty livers occur very frequently in the infants and children 
who die at the New York Foundling Hospital, or in about 41 per cent, 
of all cases. 

"3. The condition of nutrition of the child, as expressed by the absence 
of fat in general and wasting of tissue, apparently has no connection with 
the fatty condition of the liver, the condition of nutrition in the cases 



SUBPHRENIC ABSCESS. 385 

haying fatty livers averaging about the same as in the whole number of 
cases. 

"4. Fatty livers occur rarely in the following chronic wasting diseases: 

marasmus, malnutrition, rachitis, and syphilis, unless such condition be 
complicated by an acute disease. 

"5. With tuberculosis fatty livers occur not more often than with other 
conditions. 

"ii. Fatty livers occur most often with the acute infectious diseases and 
gastro-intestinal disorders. 

"7. The two cases of cirrhosis of the liver examined by the writer ran 
a comparatively acute course. The livers on section showed a marked 
hyperplasia of the so-called new-formed bile ducts. 

"8. Focal necrosis of the liver may be a lesion of measles/' 

Eead articles on "Liver/' "Bile," and "Congenital Obliteration of the 
Bile Ducts" in the chapter on "The New-born Baby/' 

Subphrenic Abscess. 

This condition is very rare in children. It consists of an accumulation 
of pus above the liver, but beneath the diaphragm. Carl Beck has described 
this condition in extenso in a paper read before the New York Academy of 
Medicine several years ago. 

Meltzer 1 reports a case occurring in a child 2 years old. 

Jopson 2 has recently reported a case from the Children's Hospital. 
in Philadelphia. 

"Maydl 3 has studied a series of 179 cases. Of these cases, which were 
found in all ages, 10, or 5.9 per cent., were under 15 years of age. The 
causes in Maydl's cases were attributed to the stomach and duodenum, 
intestinal, pericecal (including appendicitis), echinococcus, subcutaneous 
traumatism, cholangitis, perinephritis, metastatic wounds and gunshot in- 
juries, and caries of the ribs. 

Jopson, in reporting the causes of 12 of his cases, includes appendi- 
citis, perforated gastric or duodenal ulcer, caries of the dorsal vertebras, 
traumatism, and calculous cholecystitis. 

In a case reported by A. Frederick a girl, 8 years old, had an abscess 
which ruptured into the lung. The diagnosis of subphrenic abscess, second- 
ary to liver abscess, was founded on tenderness over the liver region before 
the abscess ruptured, and on the absence of air in the abscess cavity. 

Baginsky reported a case in a child, 2 1 /> years old, secondary to 
appendicitis. 



'New York Medical Journal, June 24, 1893. 
-Archives of Pediatrics, February, 1904. 

3 "Subphrenic Abscess," Wien, 1894. 

4 In Monatschr. f. Kinderheilk., July, 1903. 



CHAPTEE IV. 
DISEASES OF THE SPLEEN AND PANCREAS. 

The Spleen. 

One of the most difficult organs of a child to examine is the spleen. 
It can be palpated between the ninth and eleventh ribs. It is impossible 
to positively outline the spleen by percussion. For the purpose of examina- 
tion the child should be placed flat on its back with the thighs flexed. By 
gentle manipulation with the tips of the lingers, we can frequently in a 
quiet child press under the free border of the ribs and feel the smooth border 
of the spleen. Some authors maintain that when the spleen is palpable 
it is enlarged. I have frequently been able to palpate the spleen in per- 
fectly normal infants. 

There are no primary diseases of the spleen, although it is frequently 
the seat of tubercular disease. 

Enlargement of the Spleen (Splenitis). 

An enlarged spleen is frequently seen in various systemic conditions. 
It is one of the characteristic symptoms of many of the acute infectious 
diseases. It is a prominent symptom of malarial infection and typhoid 
fever, and next to the condition of the blood itself is a very valuable aid 
in the diagnosis. In cachectic conditions and in such constitutional dis- 
orders affecting the blood, as, for example, in rickets, a very large spleen 
can frequently be palpated. An enlargement of the spleen reaching into 
the groin was seen by me in a case of rickets. The spleen, therefore, is a 
very valuable aid to diagnosis in many conditions. For a description of 
the method of examination see article on the " Spleen in the New-born 
Baby." 

Wandering Spleen (Movable Spleen, Lien Mobilis). 

When there is an elongation of the gastro-lienal ligament, the spleen 
can be readily moved. 

Causes. — Severe paroxysms of coughing, such as whooping-cough or 
traumatism, can cause this condition. 

Symptoms. — In young children there are no special guides. Older 
children complain of pain on the left side and vague abdominal pains. 
(386) 



THE PA> 



w 



Diagnosis. — The diagnosis is made by palpating the wandering spk*en. 

Treatment. — An abdominal bandage to support the abdomen will fre- 
quently aid in replacing the spleen. Barely will surgical treatment be 
demanded. 

The Pawceb 

The pan situated behind the stomach. It is about the height 

of the first lumbar vertebra. The function of the pancreas is known as 
the amylolyiic function, namely, starch digestion, in reality the conversion 
; ~:arch into susar. 



Diseases r the Pah 

Syphilitic tissue changes are frequently seen in the pancreas. V 
nant tumors are occasionally reported in the literature. When such lesions 
exist they tax the diagnostic skill of the specialist. The diagnosis is rarely 
made infra viiam. 



CHAPTEE V. 
DISEASES OF THE PERITONEUM. 

Acute Peritonitis. 

This is a very rare condition in childhood. It is most frequently 
seen in practice in the new-born, where the inflammation is the result of 
a pyogenic infection through the umbilical vessels. This has been de- 
scribed in the chapter on the "New-born Baby." 

Etiology. — This inflammation is frequently the result of traumatism. 
It may follow the operation for appendicitis or other operation on the 
abdomen. Cases have been reported where an infection such as gonor- 
rhoea or vulvo-vaginitis has extended into the uterus or into the perito- 
neum. This condition may frequently accompany Pott's disease or peri- 
nephritis, and may also follow deep-seated burns in which cellulitis or ery- 
sipelatous inflammation exists. 

I have seen peritonitis as a complication of scarlet fever in hospital 
and private practice. 

Bacteriology. — The streptococcus is most frequently found to be the 
cause of peritonitis in the new-born. Sometimes the pneumococcus and 
the bacterium coli communi are found. 

Pathology. — Serous Form: There is a large outpouring of serum 
which is clear, and there is a small amount of lymph associated with it. 
When recovery takes place the serum is absorbed. Adhesions usually 
follow. 

Fibrinous Form. — The peritoneum is intensely congested. The blood- 
vessels injected and a large amount of lymph is thrown out with very little 
serum. The pathological process corresponds to that condition seen in 
fibrinous pleurisy. Firm adhesions resulting in the formation of connec- 
tive tissue bands usually remain. 

Purulent Form. — A large amount of lymph and pus are present with 
the usual evidences of inflammation. The abscess is rarely localized or 
isolated from the rest of the peritoneum by a thick wall of fibrin. Spon- 
taneous evacuation of pus through the vagina, rectum, bladder, or um- 
bilicus has been reported. Such cases may recover. As a rule purulent 
peritonitis is fatal. 

Symptoms. — The symptoms of fever, vomiting with pain, and uniform 

distention of the abdomen, are usually present. There is also tympanites, 

and when liquid is present fluctuation can be felt. The child is usually 

found flat on its back with the legs flexed. Diarrhoea exists in some cases, 

(388) 



CHRONIC PERITONITIS. 

constipation in others. The child appear? very sick and suffers continuous 
pain. The following case occurred in my practice: — 

Jessie M.. 2 years old; had typical symptoms of influenza. There were eoryza, 

sneezing, and a temperature of 104° F. At this time there had been a house 
epidemic, and all members of the family were suffering with influenza. The child 
had anorexia and vomiting, and cried continuously a> if in pain. The abdomen was 
distended, and constipation reported. A soap-water enema was ordered, and, 
although a good result followed, the crying continued. The abdomen was tympanitic 
on percussion and the uniform distention continued. An ice-bag was ordered, but 
gave no relief. Local applications of warm antiphlogistine poultices seemed to afford 
relief. Chamomile injections at a temperature of 115° F. were ordered given into the 
colon. When the same passed off another injection of S ounces of warm olive-oil 
not only relieved the child, but produced sleep. These injections were repeated three 
times a day. Codeine with calcined magnesia was ordered to relieve pain and for 
the antifermentative effect. 

Feeding. — Whey was given every four hours and several teaspoonfuls of 
Mulford's predigested beef with whisky every two hours. The disease lasted about 
two weeks. The child recovered. 

Prognosis. — This disease is frequently fatal, especially the purulent 
variety. The most favorable cases are those in which there is a sero- 
fibrinous exudation. The outcome depends on the vitality at the time of 
illne— . 

Treatment. — Warm applications have served me best, although some 
authors, especially the Germans, prefer ice. Hot., moist flannels to which 
15 to 30 drops of turpentine have been added will usually relieve tym- 
panites. Codeine should be given until the child is comfortable, 1 / 10 
to V 5 grain, every two hours or oftener. My result* have been best when 
milk was omitted. Soup or broth may be given. Whey is valuable in this 
condition: also white of raw egg well beaten with sweetened water. The 
treatment described in the clinical case above cited is my usual method 
adopted. The high colon flushings are cleansing and soothing. When 
great prostration exists, instead of using chamomile tea and warm olive-oil, 
normal saline solution has a more toning effect. Special symptoms, such 
as collapse, require strychnine, nitro-glycerine. or caffeine sodium benzoate. 
Also liberal stimulation with champagne or wdiisky. Oxygen if cyanosis 
exists. 

Operative Treatment. — If symptoms of appendicitis exist, then an 
operation may do good. If a sudden collapse is noted perforation should 
be suspected and the surgeon consulted at once. 

CHBONIC PeRITOXITIS (XoX'-TUBERCULOrs). 

Many authors doubt the existence of a non-tuberculous peritonitis. 
Henoch believes that we have a distinct variety of chronic peritonitis which 
bears no relation to tuberculosis 



390 DISEASES OF THE PERITONEUM. 

Symptoms. — In a distended abdomen associated with ascites the liquid 
can be made out by palpation. There may be diarrhoea or there may be 
constipation. Dyspeptic symptoms are always present, and there is a 
slight rise of temperature. There are no other symptoms of tuberculosis, 
and as a rule no other complications present, xlnamria is usually very 
marked. 

A child 8 years old was seen by me during my service in the German Poliklinik. 
He was a bottle-fed and rachitic boy. He had suffered ivith a very severe acute milk 
infection, resulting in cholera infantum and peritonitis. The child developed 
symptoms of athrepsia infantum. Several years later the child had a swollen, tym- 
panitic abdomen and a wave of fluid could be made out by careful palpation. I aspi- 
rated about 1 pint of a yellow serous fluid. The same was examined and no tubercle 
bacilli or other bacteria were found. The condition improved. The case was seen 
by me twice a month, and it was necessary to tap the abdomen each time to relieve 
distention. The child was under observation about six years. During this time 
large doses of iodide of sodium, codliver-oiL and iron were ordered. A change to 
the country seemed to do the most good. The child is well to-day. 

Tuberculous Peritonitis. 

The peritoneum frequently participates in a general tuberculous con- 
dition. It may, however, be an entirely independent disease; that is, it 
may occur as the primary lesion of tuberculosis. Biedert 1 collected a series 
of 883 autopsies on tuberculous children of various ages. He found the 
peritoneum affected in 18 per cent. The disease may be either acute or 
chronic. 

Pathology. — In tubercular peritonitis the lesions are those of a general 
miliary tuberculosis. There are usually not very many tubercles scattered 
through the peritoneum. When the ascites is present then the tubercles 
are far more abundant. The omentum and mesentery participate in the 
tuberculous process. The liquid present may be brownish-colored serum 
containing blood ; it may be serous or yellowish and contain pus. 

The fibrous form usually shows adhesions between the loops of intes- 
tine or between the intestine and the abdominal wall. In the ulcerative 
form there is usually a fibrinous exudation. This form usually follows the 
miliary or fibrous variety. 

Symptoms. — Well-marked evidences of peritonitis can usually be made 
out when ascites and tympanites are present. When fever is associated 
with it in addition to evidence of cough or other physical signs in the lungs, 
then the diagnosis is not doubtful. Sometimes the tubercular or non- 
tubercular forms of chronic peritonitis will render the diagnosis very diffi- 
cult. 

Differential Points. — Cirrhosis of the liver may cause an ascites. It 
is rare in very young children. If the history of syphilis is given the 



Jahrbuch fur Kinderheilkunde, xxi, p. 178. 



TUBERCULOUS PERITONITIS. 



391 



Bame may be suspected. In some cases a diagnosis can only be made when 
an exploratory puncture is made and the fluid examined. Even then the 
diagnosis may be difficult. The only method then left is to make a micro- 
scopical examination of the iibrous nodules or rarely by inoculation experi- 





















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Fig. 118. — Case of Tubercular Peritonitis Complicated by Tubercular 
Empyema. Enlarged Spleen. Kachitic Bottle-fed Infant. (Original.) 



ments. The following cases represent tubercular peritonitis as occurring in 
my private practice : — 

M. B., female, 2 years old, was brought to me with a history of cough, dis- 
tended abdomen, and severe constipation alternating with diarrhoea. The appetite 
was poor, and the child had lost considerable in weight and has not been well since 
an attack of measles which occurred about one year ago. Evidences of tuberculosis 
were made out. The stool contained mucus. Tubercle bacilli were frequently found 
in the mucous discharges. A cavity could be made out at the left apex. The child 
suffered with jecurring pleurisy. The chest contained a large quantity of liquid 



392 DISEASES OF THE PERITONEUM. 

effusion for over four months. Nine ounces of a thin, greenish fluid was aspirated 
from the left side of the thorax. Examination showed tubercle bacilli and also 
streptococci. The abdomen was enormously distended, and a wave or distinct thrill 
of liquid could be felt by transmitted palpation. Extreme dyspnoea was caused by 
the pressure of this liquid on the diaphragm. By aspiration I removed 1000 cubic 
centimeters of a yellowish serous liquid from the abdominal cavity. Temporary relief 
was afforded, although the abdomen refilled very rapidly. It was necessary to tap 
the same once every six weeks. The child finally died of exhaustion. (See Fig. 118.) 
A second case occurred in a little girl, Katie B., about 9 years old, who was 
under the treatment of Dr. John H. Wurthman. The same symptoms as I have 
described in the previous case were found, general tuberculosis with especial pul- 
monary manifestations and symptoms of peritonitis. In this case I aspirated over 
three pints of liquid from the abdominal cavity. The child gradually sank and died 
several months later. 

Prognosis. — When ascites is present the prognosis is not good/ espe- 
cially if operative measures are undertaken. As a rule cases end fatally. 

Treatment. — For a number of years laparotomy was advised as the 
best method of treating tubercular peritonitis. Many successful cases were 
reported. It was believed that after the abdomen was opened, drained, and 
sunlight admitted this latter agent aided the healing process. In recent 
years many pediatricians hold the opposite view. 

Light Treatment. — Not very long ago I saw a case of tubercular peri- 
tonitis (non-operative) which was progressing very nicely. It was under 
the treatment of direct sun rays, besides receiving an electric light bath for 
ten minutes each day. The influence of light has in recent years demon- 
strated its value, especially in tubercular manifestations. 

A very interesting monograph on this subject has been published by 
Aldibert, of Paris, 1892. Baginsky extols the value of operative procedures 
in tubercular peritonitis. The reader is referred to modern works on sur- 
gery for exhaustive data on this subject. 

The general treatment consists in restoratives, building up the body 
by nutrition, and by tonics when possible. 

Serum Treatment.— -The use of streptolytic serum in doses of 10 to 30 
cubic centimeters is well worth trying. Antistreptococcic serum (10 to 
50 cubic centimeters) can be injected in daily doses of 10 cubic centi- 
meters, or the dose may be given every two or three days. 



Ascites. 

This is an accumulation of clear serum in the peritoneal cavity. When 
it is very severe there is, in addition to the uniform distention of the 
abdomen, a superficial enlargement of the veins. This is especially noted 
around the veins of the umbilicus. 



AS< I I l> DUE TO PERITONITIS. 



393 



Causes. — Pressure upon the vena cava, or chronic hearl or Lung 
trouble, such as pleurisy, may give rise to ascites. In extreme Leukaemia, 
anaemia, or kidney disease ascites may be present. 

Diagnosis.— Tlu< fluid can best be made out by tapping the abdomen 
and ooting the transmission of the wave. On tapping the abdomen with 
one hand and pressing the other (irmly against the opposite side, a wave of 
fluctuation can be made out. 

The symptoms, prognosis, and treatment will be considered in the 
article on "Ascites Due to Peritonitis." 



Ascites Due to Peritonitis. 

In the majority of cases ascites is caused by tubercular peritonitis. 
This condition resembles in its clinical and pathological aspects subacute 
or chronic pleurisy with effusion, or subacute pericarditis. 

Etiology. — Xo definite cause and no specific agent has yet been deter- 
mined. Most of the cases are associated with or follow rheumatism, mea- 
sles, or exposure to cold, and in rare instances injury to the affected parts. 
It is also seen associated with diseases of the kidney, liver, and intestines. 

Pathology. — The pathological lesions are very few. The effusion is 
usually of a greenish color. In addition to the serum there is fibrin, and 
in some instances adhesions. In some cases all the serous membranes of 
the body seem to participate and show evidences of inflammatory condition. 

Symptoms. — The early symptoms of ascites consist of general malaise. 
A child will have a poor appetite, complain of headache, and sometimes 
constipation. In other cases diarrhoea may exist. Pain is not present as 
a rule. The abdominal distention comes on gradually and progresses. The 
distention is usually the first symptom noted by the mother. The fluid 
can best be made out by tapping the abdomen as described in the foregoing 
article on "Ascites." Fever is usually absent, although there may be an 
evening temperature of 101° F. 

Prognosis. — The prognosis is fair as a rule. I have seen many cases 
of ascites recover, leaving no trace of the former trouble behind. A cautious 
prognosis is advised if a tuberculous process is suspected. 

Treatment. — General Treatment: Such children must be put to bed. 
The diet should consist of concentrated liquid food. Xo solid meats should 
he permitted. Milk, if not well borne, should be peptonized or fermented. 
Buttermilk may be recommended. Fresh air and sponge bathing should be 
remembered as important hygienic factors. 

The body should be well protected to avoid chilling the surface. 

Treatment of the Effusion. — Small doses of calomel or podophyllin 
may be give^ until liquid stools are produced. Diuretics such as cream of 
tartar, lemonade, or diuretin, in 5-grain doses, will stimulate the action of 
the kidnevs and thus lessen indirectly the serous effusion in the abdomen. 



394 DISEASES OF THE PERITONEUM. 

Iodide of sodium in 3- to 10- grain doses should be given three times a 
day to promote absorption. It may be combined with iron in the follow- 
ing manner: — 

I£ Ferri et kali tartaric 1 drachm 

Sodium iodide 1 drachm 

Elix. of lactopeptin, q. s. ad 2 ounces 

Sig. : One teaspoonful three times a day. 

Tapping the Abdomen. — Aspirating the liquid by means of a trocar 
and cannula is a valuable means of emptying the liquid. It is especially 
indicated if symptoms of dyspnoea due to pressure on the diaphragm are 
noted. 

If relapse occurs and the liquid continues to accumulate after several 
aspirations, then surgical treatment will be necessary. The occasional good 
results seen in tubercular peritonitis after a laparotomy should be remem- 
bered. 



CHAPTER VI. 
DISEASES OF THE GENITAL ORGANS. 

Hernia. 1 

Hernia is occasionally seen in the new-born baby. It is overlooked 
in a good many cases until the size of the tumor indicates that something 
is abnormal, as there are no special symptoms (see article on "Hygiene ot 
the Infant" in the "New-born Infant"). 

"In congenital hernia proper, anatomical conditions favorable to vis- 
ceral escape always tend to permanent spontaneous cure in infancy and 
early childhood. At birth the spermatic vessels are deeply covered by a 
thick layer of adipose tissue. The dartos and cremaster are then highly 
developed, giving the scrotum dimensions quite out of proportion in size 
to what they are in adult life. Serous cysts of the tunica spermatica and 
of the tunica vaginalis being very common, this condition also with the 
scrotum fullness may simulate hernia so closely that it is only by a most 
painstaking examination we are enabled to exclude them. On the other 
hand, a small fringe of omentum may come down with the cord and be 
completely overlooked.*' 

Thomas H. Manley, in his monograph on "Hernia and its Treatment," 
says : "The prevalent custom of applying a band or binder around the 
abdomen should be condemned. It conserves no useful purpose ; the only 
excuse for it at all is that it retains the envelopes of the funis in position. 
If this firm, inelastic compression does not in many cases directly cause 
hernia in those predisposed to it, I am confident it often very seriously 
interferes with spontaneous cure, by the increasing pressure which it pro- 
duces against the abdominal walls. In the herniated infant this, then, 
should be cast aside, the dressing for the navel string being held in position 
by adhesive straps or tapes passed around the body. After the desiccated 
remnant of the cord has dropped off nothing whatever in the way of a 
girth should be worn around the abdomen, but the garments, when the 
erect attitude is taken, should be all carried from the shoulders, thereby 
the feeblest possible action being given to the diaphragm and the organs 
of digestion. Occasionally we see one side of the scrotum occupied by a 
hernia before the testicle has descended. Congenital hernia is very rare 
in females. In the female the umbilical hernia is more common." 

Causes. — A calculus in any portion of the urethra or a phimosis or 
atresia of the urethral canal may cause powerful contractions of the ab- 



1 For Umbilical Hernia see chapter on "Diseases of the Intestines." 

(395) 



396 DISEASES OF THE GENITAL ORGANS. 

dominal muscles, resulting in a hernia. Coughing, especially whooping- 
cough, frequently produces hernia. Constant straining efforts during con- 
stipation or when diarrhoea persists frequently end in hernia. 

Symptoms. — In male infants a tumor that is soft and round will be 
found in the scrotum. The testicle, although at times difficult to feel, is 
usually felt above or behind the swelling. This swelling consists of a loop 
of intestine; rarely the peritoneum descends with it. By placing the child 
on its back the swelling can easily be pushed into the abdomen through the 
abdominal ring. There is always a gurgling sound, which is characteristic 
of hernia. 

Diagnosis.— Hernia is frequently mistaken for hydrocele. Both hy- 
drocele and hernia are sometimes found in the same case. The following 
differential points are well worth noting : — 

ABLE No. 59. 

Hydrocele. Hernia. 

1. Translucent by transmitted light. 1. Is opaque. 

2. Always dull on percussion. 2. Always resonant. 

3. When reduction is possible the 3. The hernia passes back quickly 

fluid passes back slowly and and gives the characteristic 

noiselessly. gurgling sound. 

4. No impulse on coughing. 4. An impulse can be felt when 

patient coughs. 

5. The ring is empty. 5. The ring is filled with the neck of 

the tumor. 



Prognosis. — This is usually good. Children rarely have strangulation 
as we find it in adults. Most of the cases of hernia seen by me in children 
recovered with the aid of a properly fitting truss. At times nothing but an 
operation will cure the case. 

Treatment. — The diet should be regulated. If any apparent cause 
exists, such as prolonged diarrhoeas with tenesmus, constipation, or cough, 
the same should be treated. If a whooping-cough exists the proper treat- 
ment must be instituted before mechanical appliance is ordered. This 
consists chiefly in relieving the hernia with a truss. My own experience 
has been rather good by having a rubber sponge with a rough surface made 
to include the hernia. This should be held in place by the usual strap 
going around the body. The leather covered or the celluloid front pads 
are continually slipping; hence, not so well adapted for children. The 
hygiene should be well considered in a child. A truss on a diapered infant 
is a nuisance ; it cannot be kept clean ; hence, every nurse or mother should 
be instructed regarding the sensitive skin and the danger of causing irri- 
tation from moisture. Every mother 'should be taught to watch the infant 
when it cries or strains to prevent the truss from slipping. 



phimosis. 



97 



Surgical Treatment. — With modem aseptic methods there is little 
or no risk in an operation. The success of the Bassini operation is so 
uniform that 1 have seen do/ens of children operated with no fatalities. 

For the details of this surgical method 1 would refer the reader to text- 



hooks on surgery 



Hydrocele. 



"The testicle in its descent is surrounded by a serous membrane 
described by some authors as a serous pouch. When this pouch fills with 
serum it is called a hydrocele. Normally a few drops of serum are found 
in the tunica vaginalis propria. Larger accumulations are met with in 
more than 10 per cent, of male infants, mostly on the right side, seldom 
on both. In the majority of cases there is no longer a communication 
with the abdominal cavitv. When it remains a hernia may complicate 
the hydrocele and the diagnosis be more difficult, because the fluid is apt to 
return occasionally into the abdomen. Spontaneous absorption is not very 
rare, but suppuration is uncommon.*' 

Treatment. — Under aseptic precautions a sterilized needle or trocar 
should be introduced. By this means the serum can be removed. This 
simple method has frequently resulted in a cure. W^hen the hydrocele fills 
up again the injection of a few drops of tincture of iodine or Lugol's solu- 
tion, or pure carbolic acid after the serum has been withdrawn, will usually 
prove successful. Operations are rarely required, although they are indi- 
cated if this milder form of treatment proves unsuccessful. 



Adherent Prepuce. 

Congenital agglutination of the prepuce and the glans penis is occa- 
sionally reported. The majority of cases seen are acquired conditions. 
Smegma frequently collects under the foreskin when the same is not prop- 
erly cleaned. 

Treatment. — With a blunt probe an adherent prepuce can be loosened 
from the glans penis. The smegma should be removed and the parts 
lubricated with albolene or olive-oil. The mother or nurse should be 
instructed to oil these parts and thoroughly separate the prepuce so that 
new adhesions do not form. If this trouble recurs then circumcision is 
indicated. 

Phimosis. 



Phimosis is due to a narrowing or contraction of the prepuce so 



that the foreskin is prevented from being drawn back over the glans 
penis. A tight prepuce or an elongated prepuce is a constant source of 
irritation. Bed wetting is a very frequent symptom of this condition. 
There is an itching and an irritation which frequently lead to bad habits. 
The sensitive condition sometimes causes priapism, and this may lead to 



398 DISEASES OF THE GEXITAL ORGANS. 

masturbation. Night terrors and insomnia are frequently caused by this 
condition. Phimosis is sometimes an exciting cause of chorea and various 
nervous diseases. 

Symptoms. — Such children invariably surfer with anaemia. They are 
peevish and restless and constantly irritable. The main symptoms are a 
series of irritations caused by the tight foreskin as outlined above. In 
exceptional instances strong, healthy children may not show any symptoms 
of this condition. 

The following case was seen by me in private practice: — 

A boy, 4 years old, has always been in apparently good health. He was 
breast-fed, well-nourished, and showed no evidence of rickets. His mother com- 
plained to me that the child had a "weak bladder," that he could not hold his urine, 
especially at night. He was restless and peevish, and tossed about in his sleep. 
On examination I found a phimosis existed. The prepuce did not slip over the 
glans, and the child cried as though in pain whenever the genitals were touched. 
I advised stretching the foreskin, and this was done every few days, with some degree 
of success, for the period of about three months. The child improved. When seen 
again about one year later the symptoms of nervousness, and restlessness reappeared. 
I then advised circumcision. With the assistance of Dr. John H. Wurthman, who 
administered chloroform, the prepuce was removed, the parts were dusted with 
europhen, and the wound healed per prim an. The child improved gradually and is a 
good healthy child to-day. 

Treatment. — The treatment outlined in the case above described is the 
only one that should be used : First, stretching the prepuce, and, secondly, 
if this does not afford relief, circumcision. 

Operation. — A simple method is to make an incision or cut the dorsum 
of the prepuce with a scissors. After this incision is made we invariably 
have another skin to divide, which is the mucous membrane. Unless this 
is also incised we cannot expect relief from the constriction. As a rule small, 
cheese-like particles, called smegma, will be found, which must be cleaned 
away. Then follows the surgical treatment, such as checking haemorrhage, 
if the same is profuse. In rare cases one or more stitches may be necessary 
to control the bleeding. I invariably use a piece of sterile gauze saturated 
with MonsePs solution immediately after the operation, then dust the parts 
with europhen. Great care should be used to avoid infection from a case 
of diphtheria or erysipelas. It is safer to have a surgeon supervise or per- 
form the operation than to run the risk of infection. 

Paraphimosis. 

This is a condition caused by the swelling of the glans or by an abnor- 
mally small preputial orifice. 

Treatment. — Have the thumb and finger of one hand pressing on the 
glans; with the other hand an attempt should be made to draw the prepuce 



CRYPTORCHIDISM. 39!) 

back in position. In some cases Immersing the parte in very warm water 
for several minutes lias served me very well. II' the parts are very tendei 
a spray of ethyl chloride can he used with advantage before the attempted 
reduction. When the parts are very (edematous then puncturing the sur- 
face to relieve the serum will sometimes yield good results. At times sur- 
gical relief may he demanded. 

Hypospadias. 

The urethra sometimes opens on the under side of the penis. This is 
always a congenital condition. 

A case of this kind was seen be me in consultation with Dr. Julius Brandeis, of 
Xew York City. When I saw this infant it was three days old and apparently 
suffering pain. The bladder was distended, and the infant had not urinated, 
according to the history given, since it was born. An examination showed a 
hypospadias. The urethral orifice in the glans penis was absent. With the aid 
of diuretics and a warm hip bath the infant urinated. I have seen this child many 
times since. He is now able to walk and talk and suffers no inconvenience. 

The treatment is radical — by means of plastic surgery. 

Epispadias. 

In this' condition the opening of the urethra is on the superior surface 
of the penis. It is less frequently met with than hypospadias. 

The treatment is distinctly surgical and requires a plastic operation. 

Cryptorchidism (Undescended Testicle). 

The testes usually descend into the scrotum during the ninth month 
of pregnancy. In some children the testicles may remain in the inguinal 
canal or even in the abdomen. 

Ralph C. was referred to me by Dr. W. Freudenthal. He was a well-nourished, 
healthy child. Was breast-fed and in apparent good health until two years ago. 
He suffered with cough, was a mouth breather, and snored at night, for the relief 
of which Dr. Freudenthal removed his adenoids. The child was brought to me for 
the relief of an irritable and restless condition. His mother stated that he scratched 
his nose and appeared to have a pruritus of the anus. The diagnosis of ascarides 
lumbricoides was made. While examining the child I found one testicle could be 
palpated in the scrotum and the other in the inguinal canal. By pressure on the 
abdomen it would descend. There were no symptoms directly attributable to this 
condition. 

Treatment. — If no irritation is caused then let it alone. If a false 
passage has been made which gives rise to pain, then the question of 
removal of the testicle may come up. The case then is distinctly surgical. 



400 DISEASES OF THE GENITAL ORGANS. 

ORCHITIS. 

An inflammation of the testicle is a rare condition in infancy. Cases 
have been reported where injury caused orchitis. In the article on "Mumps" 
orchitis is mentioned as a complication. The treatment consists in rest and 
ice-cold applications of lead and opium. Laxatives are indicated to open 
the bowels and thus help relieve the inflammation. 

Urethritis : Vulvo-vaginitis. 

Vulvo-vaginitis is a catarrhal infectious disease involving the female 
genital tract. It is divided into : — 

(a) Simple or Catarrhal; (6) Gonorrheal. 

Simple Vaginitis. 

The normal urethra of both male and female children, also the vagina, 
frequently has a simple catarrh. The symptoms noticed are those of swell- 
ing, inflammation and a catarrhal secretion. 

Etiology and Bacteriology. — Normally the vagina contains a white 
diplococcus which is not decolorized by Gram. 

In simple catarrhal vulvo-vaginitis we have a white diplococcus which 
also is not decolorized by Gram. 

In gonorrheal vulvo-vaginitis we have a white diplococcus which does 
not decolorize by Gram, and in addition thereto a yellow diplococcus called 
D. Flavus (Bumm). 

These germs are usually found in conjunction with other micro-organ- 
isms or with streptococci. They easily stain with a watery solution of eosin 
and counterstain with an alkaline aqueous methylene blue solution. 

The microscopical examination shows leucocytes, epithelium, and 
various micro-organisms; never gonococci. 

Symptoms. — The parts are usually sensitive to pressure. 

Children who are old enough complain of pain on urination, and also 
urinate very frequently. In very young children it is impossible, in fact, 
unnecessar}^ to make a vaginal or uterine examination. 

This disease may last for months, especially so if the body is in a 
subnormal condition. 

This simple catarrh affecting the vulvo-vagina is highly contagious, 
hence each case should be strictly isolated. 

Children so afflicted should sleep alone. 

Gonorrhoeae Vaginitis. 

Gonorrheal vulvo-vaginitis is frequently met with in practice. As a 
rule it occurs among poorer classes where families are crowded and un- 
sanitary. Frequently the infection is transmitted from the adult to the 



(.JONOUKlliKAL VAGINITIS. 



401 



child by Bleeping in an infected bed. Cases are on record where a mother 
suffering with gonorrhoea] vulvo-vaginitis has infected her child while 

sleeping with it. 

Etiology. — The slightest abrasion of the skin will permit the entrance 
of the gonococcus. Cases have been reported in which a healthy person was 

infected by taking a hath in the same tub in which a person affected with 
gonorrhoea had bathed the day previous. It is a well-known faci that the 
gonococcus will live twenty-four hours, hence these germs will persist in the 
tnh ami can transmit infection. For this reason a separate tub should 
be procured while gonorrhoea] disease exists. 

Bacteriology. — Gonorrheal vaginitis is caused by the presence of the 
gonococcus. It is necessary, however, to subject the gonococcus described 
by Neisser to the Gram method of staining. The diplococcns found in the 
normal urethra can easily be differentiated by subjecting the same to the 
Gram stain. Normally the gonococcus has never been found in the vulvo- 
vaginal tract or in the normal urethra. The gonococcus can easily he 
stained with a 2 per cent, alcoholic methylene blue solution. 

Mode of Infection. — Direct transmission of infected matter from adults 
to children has been known to occur. Infected clothing, especially bed 
linen, has transmitted this disease. 

In rare instances the infection has taken place directly during the 
sexual act. There is a popular superstition that when an adult male has 
gonorrhoea he will be cured by raping a healthy child. An instance of this 
kind has occurred in my practice. 




Fig. 110. — Gonococcus. (Gonorrhoeal Pus.) Stained one-half minute 
with methylene-bhie. o, Free in groups, b, Enclosed in pus cells. Leitz 
ocular T. Oil imersion V ia . (Lenhartz-Brooks.) 



402 DISEASES OF THE GENITAL ORGANS 

A little girl, 6 years old, apparently healthy, was infected by an adult suffering 
with gonorrhoea. She suffered continuously for over four months until brought to 
me, when her vulva, vagina, and urethra were one mass of inflammation. There 
was a greenish yellow discharge. The bacteriological examination showed diplococci 
in the leucocytes. 

The child was put to bed and a sterilized pad applied over the genitals. This 
pad was changed every four hours. A site bath of 1 to 2000 warm bichloride was 
ordered morning and evening, lasting twenty minutes. A vaginal injection of 5 per 
.cent- argyrol solution was given immediately after each bath. Internally iron 
was given. The discharge continued eleven days and everything seemed well. A 
reinfection evidently took place four days after having stopped the active treatment, 
as the discharge appeared with renewed vigor. The child was again carefully 
treated with astringents. The discharge persisted for three months, when it was 
finally cured. 

Complications. — The Eye: The danzer of transmitting gonorrhoeal 
infection by the hands from the genitals to the eyes must always be re- 
membered. That this form of infection is not without danger is well 
known. At the Riverside Hospital in the scarlet fever wards, during the 
summer of 19C 2 . I sa-v a child that was totally blind, the result of a gonor- 
rhoeal infection. 

The Joint. — We occasionally meet with symptoms of inflammation 
involving one large joint; this is called monarthritis. An inflammation 
of this kind usually means gonorrhoeal infection. 

T ~:e Heart. — When the gonococcus enters the circulation it frequently 
attacks the valves of the heart. Valvular lesions are similar to joint lesions, 
hence we must not be surprised to see cases reported in which a gonorrhoea 
started at the genital tract, entered the circulation, and involved the heart. 
A case of this kind was reported by Leyden, of Berlin. 

Pyelitis caused by an extension of this infection from the urethra may 
end fatally. An infection may spread from the vagina into the uterus and 
set up a salpingitis and end fatally. On the other hand this disease, i: 
neglected, may assume a chronic tendency and cause sterility, so that a 
guarded prognosis should be given in every case until the infection is modi- 
fied and the outlook is good. (Eead article on ^Pyelitis.") 

Ytlvo-vagixitis Foil:":::;- Scarlet Fzvee. 
At the Eiverside Hospital during the summer of 1903, out of 100 cases 
of scarlet fever there were 15 cases suffering with vulvo-vaginitis. In these 
there was a well-marked purulent discharge upon the deeper parts of the 
vulva and at the vaginal opening, with some redness and irritation. ' ::.: 
this there was a distinct rise of temperature and some constitutional distur- 
bance. The cases all yielded promptly to treatment, proving especially 
amenable to simple astringent solutions rather than to more active ger- 
micides. '- 



Reported to me bv Dr. G. L. Nicholas.. Resident Physician. 



VULVOVAGINITIS FOLLOWING SCARLET FEVER. 



in:; 



It is n«'i uncommon to find cases of vulvitis and also vaginitis occurring 
in the scarlet-fever wards for which there is do adequate explanation. 

Vulvo-vaginitis as Beeu at the Riverside Hospital occurs as a distinct 
complication to scarlet fever. When it ocean's it shows a distinct rise of 
temperature and also a peculiar constitutional disturbance. When this 
i- contrasted with the symptoms of a catarrhal otitis the similarity of both 
conditions musi be apparent. Not only do we have similar bacteriological 
findings, bui the infection manifests itself in a rise of temperature and 
genera] systematic disturbance. 

Whilo an occasional case of true gonorrheal disease may arise in 
which the Neisser gonococcus will be found, from a large clinical experience 
in both hospital and private practice, I must say that such cases are very 

ptional. 

Prognosis. — The prognosis is usually good, although we must hear in 
mind that if these cases are neglected serious result- may follow. Infection 
may spread from the urethra into the bladder and from the bladder into 
the ureters, and infect the kidneys. 

Treatment. — Hygienic Treatment. — In this disease more than in any 
other the strictest attention to hygienic rules is demanded. If it is an 
infant that is so afflicted, the pads should thoroughly cover the vulva and 
be saturated with a weak 'solution of bichloride. This pad should be ad- 
justed with the aid of a T -binder. If there is severe itching from excoria- 
tion and the child has a tendency to scratch, the hands should be guarded 
so that the infection cannot be carried from the genital tract to the eyes. 

Local Treatment. — Labarraque's solution is a very valuable remedy. 
It may be used in a 5 per cent, solution. My plan, has been to add about 
1 ounce of chlorine water to 1 pint of lukewarm water and irrigate morn- 
ing and evening, noting the effect. If the discharge is not lessened thereby, 
the injection should be given three times a day. 

Astringent solutions, such as sulpho-carbolate of zinc, sulphate of zinc, 
or sulphate of copper, using 1 grain to the ounce, are useful. When there 
is intense itching it is a wise plan to instill a 2 per cent, ichthyol glycerine 
solution into the vagina after the same has been thoroughly washed with 
one of the above astringent solutions. 

Argyrol. 25 per cent, solution, has been used as an injection several 
times a day with remarkable success at the Willard Parker Hospital by 
Dr. Studdiford. 

The persistence of vulvo-vaginitis in spite of the local methods of 
treatment has led to the trial of a new form of treatment. From the growth 
of bacteria taken from the vaginal discharge, injections of an emulsion of 
50,000,000 bacteria were given hypodermically. Such injections were 
repeated once daily. The dose was increased to 00 and 70,000,000 bacteria. 
These injections used at the Willard Parker Hospital have proven very sue- 



404 DISEASES OF THE GENITAL ORGANS. 

cessful and may open a new form of treatment. Cultures grown were made 
under the supervision of Dr. Wm. H. Park in charge of the Research 
Laboratory. 

Constitutional Treatment. — Iron and codliver-oil should be given for 
several months as a restorative. Persistent local treatment alone is fre- 
quently of no avail, and I have noticed that this condition persists until 
iron, arsenic, or other similar tonics are given internally. The value of 

nutrition must not be underestimated. 

- • 

Vicarious Mexstruatiox. 

Some children have a periodical nose bleed recurring every three or 
four weeks. In some cases there is a considerable flow of blood lasting 
between two and five days. In making the diagnosis it is important to 
exclude all diseases due to local causes, such as polypus or haemophilia. 
In one case seen by me (see chapter on ''Syphilis**) fatal haemorrhage 
resulted in a case of congenital syphilis. 

The cause is unknown. 

Treatment. — The body should be strengthened and iron given inter- 
nally. A change of air to the seashore or mountains will strengthen the 
body and frequently relieve this condition. 

Menstruation Precox. 

We occasionally see girls from 6 to 10 years of age with regular men- 
struation. Literature records numerous cases of children from 2 to 5 years 
of age with regular recurring menstruation. Such menstruation lasts sev- 
eral days or in some instances several hours. As a rule such children are 
delicate, tuberculous, or syphilitic. 

Symptoms. — There is usually pain in the abdomen similar to colic, 
restlessness, and a series of nervous symptoms. Such children are hard 
to please. 

Diagnosis. — It is necessary to exclude local causes, such as papillo- 
matous or polypoid excrescences. I have previously referred to haemophilia 
and to syphilis as a possible cause. Local causes, such as masturbation or 
traumatism, must be excluded. As a sequela to acute infectious diseases, 
we frequently have vaginal catarrh. This discharge may sometimes be 
mixed with blood. The diagnosis depends on the regularity of the periods 
recurring every three or four weeks. 

Treatment. — Warm demulcent drinks and the avoidance of cooling 
liquids. The child should be kept in bed and warmly dressed. 

If the bleeding is very profuse then 5 to 10 drops of fluid extract of 
ergot (Squibb's), or hydrastinin hydrochlorate, 1 / 10 to 1 / 20 grain, three 
times a day, may be given. An ice-bag over the abdomen will frequently 
relieve severe pain and check profuse bleeding. 



CHAPTER VII. 
DISEASES OF THE KIDNEY AND BLADDER. 

The Kidney. 1 

The kidneys of an infant are proportionately larger than in adult life. 
They are also situated lo\ver than in the adult. The large size of the liver 
in infancy is the reason for the difference in position of the right and left 
kidney. The right kidney is situated lower than the left. The suprarenal 
capsules are much larger than in the adult. After the second year the 
kidneys assume the position usually occupied by the adult kidneys. 



Acute Nephritis (Acute Glomerulonephritis : Acute 
Bright's Disease). 

Primary nephritis is by no means a rare condition in childen. In 
the majority of text-books nephritis is described as the complication of 
infectious diseases. It is true that it is most often seen following the 
acute infectious diseases. In primary nephritis the source of infection is 
sometimes hard to trace. Pathogenic bacteria can reach the kidneys 
through the circulation and thus set up nephritis. 

Etiology. — The influence of exposure, "taking cold," must be looked 
upon as an associated factor in the causation of this disease. 

Comby 2 explains this as follows : — 

In the absence of a specific process, such as scarlatina, diphtheria, etc., 
we are led, upon the occurrence of acute simple nephritis, to suspect the 
influence of cold. The action of cold, however, is not always direct. In 
nephritis, as in pneumonia, cold alone does not cause the disease. It en- 
feebles the organism, increases its receptivity, augments the virulence of 
microbes, and opens the gates by which they" enter. Children carry within 
themselves, in the mouth, pharynx, and nasal passages, various microbes 
which only await an opportunity of wakening into activity. This opportu- 
nity is afforded them by the impression of cold. 

The sore throat which so often precedes nephritis constitutes a first 
step toward the invasion by pathogenic microbes. The epithelial barrier 
is broken down, the micro-organisms reach the lymphatic glands, where 
they are often arrested or may continue their progress, passing into the 



1 The urine, its physiological and pathological condition, is described in detail 
in the chapter on "Urine," Part XII. 

1 "Nephrite Aigue Simple des Enfants," pax le Dr. J. Comby, La MSdecine 
Mod erne, December 1, 1897. 

(405) 



406 DISEASES OF THE KIDNEY AND BLADDER. 

circulation, and finally excite a distant inflammation which may be, accord- 
ing to circumstances, a pneumonia, an endocarditis, or nephritis, etc. 

In some cases an apparently most trivial angina becomes complicated 
with swollen cervical glands, and, subsequently, with acute nephritis, etc. 
Cases have been described as glandular fever, or, in other words, acute 
adenitis, symptomatic of pharyngeal infection, in which nephritis has 
developed, superadded to the original disease, which it finally survives. 
These complications are not fortuitous, but are linked together in strict 
sequence. 

Pathology. — Inflammation of the kidney in a large majority of cases 
commences as a glomerulo-nephritis, the delicate walls of the capillaries, 
and their equally delicate epithelial investment being the earliest to suffer; 
and instead of the non-albuminous urine, one laden with albumin escapes. 
If the inflammation still progresses, corpuscles, especially the red, make 
their way out and produce smoky or bloody urine, the naturally high pres- 
sure in the glomerulus no doubt greatly facilitating the diapedesis. The 
casts which may now appear consist for the most part of fibrin, of red and 
w T hite corpuscles, and of renal debris, moulded in the tubes. 

The glomerular disturbance is followed by that of the rest of the vas- 
cular net-work and of the gland cells. The latter become swollen and 
"clouded," and are readily detached. The swollen cells may occlude the 
lumen of the ducts and press upon the vascular tissue without. Or the 
capillaries are congested and exudation swells the intertubular tissue. In 
any case the tissue is enlarged and softened. Sometimes during life the 
signs of nephritis are well marked, but after death the anatomical lesion 
appears very slight; in these cases comparison with a normal kidney, both 
to the naked eye and under the microscope, is invaluable, as then some 
change can usually be detected. 

The kidney of typhoid and diphtheria serve as examples, although 
there are numerous acute specific diseases which are accompanied by ne- 
phritis and albuminuria. The glomeruli are enlarged, owing to swelling 
of the interstitial substance and to engorgement of the capillaries and 
often swelling of the endothelial cells; there is in addition an increase 
in the number of nuclei in the glomeruli. Bowman's capsules may be 
slightly distended, their endothelium swollen or proliferating, and the 
spaces occupied by fibrin or white or red corpuscles. There may be an 
increase in corpuscles around the roots of the glomeruli. The tubules may 
be dilated, the epithelium swollen and granular, or there may be some 
proliferation. Casts are numerous, though usually hyaline; they may 
consist of blood. Small haemorrhages are frequent, especially in diph- 
theritic kidneys. 

Acute nephritis in the new-born has been described by Jacobi. 1 



'New York Medical Journal, January, 189G. 



JkCVTE NEPHRITIS. 






Hfpl— I — Gastric disturbances, such as vomiting, are very f re- 
qo«LiIv noted. As a role premonitory symptoms are absent. 

th fever, loss of appetite, headache, and general malairap. 
-.j* face is sometimes the fust sign of trouble. 
TAc arm* •'.* ofawjp aroaif and sometimes contains red Mood-corpus- 
cles, leucocytes, and easts. The mine shows die evidence of acute renal 
congestion and is jfarttas albmmim&ma In grave cases there are frequent 
efforts to pass mine, and these attempts are attended with pain. With great 
zLLd expels a fear drops of dark colored uriiL :4ing 

to the seTc-rirr of the case these symptoms subside after a period varying 
from ten to thirty days. Inegularity of the pulse is frequently noted, and 
should arrays be looked upon as an evidence of toxamiia. It is a grave 

~"'Z_7.~. - — 




71 f 



: :lf _-:" -L. zLi . ;'.-:'.-- i:'l:~ fc 



Prognosis. — TSifs is usually good. If treatment is neglected in an 

::'.:_"> : .... z_. z~~ zzzzi ~ _11 :-- > In :::t Lz.fT.iz: - .. : . 

faropmiia may cause convulsions and death. 

?Tr;z:.::5 l L:zTL::ir.:z — _\z- \— — ■_.;- :::•::. :z" : : LL ~ 
scarlet fever or diphtheria. It is also occasionally seen in most infectious 
dis e as e s such as typhoid, mpasJre^ varicella, pneumonia, inflnenia, malaria, 

Z_rZ:i_:~_- Z : rZZ rZii. 

In a study of gastro-enteritis made by Baginsky, the frequent asso- 
ciation of nephritis was noted. This author found that the bacterium coli 

?zLL ::-:< :z'L" : -- : - :z :. ' : - - 

Waif K_ a *irl 5 v«ars old, bad tobmilsb^. fallowed br am e iaptti aa off scarlet 
fever c waiag the- eatire body. TVe rash was disiiaet Sor fkree days aad taea 

:ii-: 7\- ::.--:::•- :: i--ri.i-.--T v/i:: - - - - : : 1 -•-".-: :,--: 7r 



408 DISEASES OF THE KIDNEY AND BLADDER. 

child was up and about during the second week following the eruption. The stomach 
was not carefully guarded, as the child was given a too liberal diet. On the twelfth 
day from the beginning of her illness she suddenly had what the family called a 
sinking spell. Evidences of heart weakness were noted. Two days later, or on 
the fourteenth day of her illness, she was again put to bed. At this time she com- 
plained of pains in her joints. The glands of the neck were swollen. The urine 
was somewhat scanty. On the seventeenth day she had three very severe convulsions. 

Owing to the careless management of this case, the family discharged the 
first attending physician. Later the family called Dr. T\j. Pechner, who saw the 
severe toxaemia and noted the anuria. I saw this case twenty-one days after the 
beginning of the disease. The diagnosis of nephritis was easily made. Hardly an 
ounce of urine was passed during the day. The child was (edematous and had the 
waxy appearance seen in acute nephritis. The heart sounds were muffled. The 
pulse-rate was slow and irregular. The temperature was very slightly elevated, 
although a severe myocarditis existed. The child was placed in bed, under the care 
of two trained nurses. 

Treatment.— Hot packs, diaphoretics, and diuretin, in doses of 5 to 20 grains, 
three and four times a day were given. Hot saline colon flushings at a temperature 
of 115° F. were ordered to stimulate diuresis. A bland liquid diet aided by liquids, 
lemonade, and cream of tartar, formed the main treatment. The child made a 
brilliant recovery. There were no complications after the disappearance of the 
nephritis. 

Secondary Xephritis. 

Secondary nephritis, following the acute infectious diseases, can best 
be studied by taking the type most frequently met with, namely, post-scar- 
latinal nephritis. (See chapter on "Scarlet Fever" for a complete descrip- 
tion of this condition. Note also the microscopical appearance of the 
urine in the Fame chapter, page 058.) 

Treatment.— Cream of tartar lemonade, a teaspoonful of cream of 
tartar, added to a tumblerful of ordinary lemonade, and sweeten. This 
should be. given freely. Another drug that has served me very well is 
diuretin; this should be administered in doses of from 3 to 15 grains, 
depending on the age. This can be repeated every three or four hours,, 
depending on the severity of the case. When diuretin is not well borne by 
mouth, I give it in the form of suppositories per rectum. 

The following has served me very well as a diuretic in nephritis when 
the urine was scanty : — 

f£ Potass, citrat 2 1 / 1> drachms 

Ext. buchu. fluid 2% drachms 

Ext. uva ursi fl. . 1 drachm 1 scruple 

Syr. limonis 2 ounces 

Aqua q. s. ad 4 ounces 

Sig. : Teaspoonful every two or three hours. 

Calomel or podophyllin, in small doses, 1 / 20 grain, repeated every two 
or three hours, is sometimes valuable in this condition. Lithia water and 



PERINEPHRITIS. 409 

the alkaline waters are generally indicated. An infusion made by scalding 
the ordinary parsley root (rad. petrosilini), using about one teaspoonful 
of the chopped root to a teacupful of boiling water, strain and sweeten. 
This can be given in large quantities whenever the child is thirsty. Sweet 
spirits of niter in doses of 1 / 2 teaspoonful, gradually increased, for a child 
1 to 5 years old, and repeated every three hours, is a safe and efficient 
diuretic. 

Jaborandi or its alkaloid, pilocarpine, are frequently advised as diu- 
retics. I have frequently seen such cardiac depression follow their admin- 
istration that I invariably warn against their use. In conclusion, I desire 
to lay great stress on the weakness of the heart frequently noticed after 
the administration of the hot-air bath. In one instance where I was called 
in consultation, the child died during the administration of such a bath. 

Perinephritis. 

An acute inflammation involving the cellular tissue which surrounds 
the kidney, as a rule terminating in suppuration. Some cases may resolve 
without suppuration. 

Etiology. — It may be associated with, or due to suppurative process in 
the kidneys. It is also found in tubercular conditions. The most frequent 
cause undoubtedly is traumatism. Idiopathic conditions are frequently a 
distinct factor. 

Perinephritis is not of frequent occurrence. Townsend gives the fol- 
lowing statistics: "Xieden, in 1897, found records of 1G6 cases. Twenty- 
three of these were under 15 years of age, the youngest being five weeks 
old. In 1880 Gibney reported a total of 28 cases; the ages varied from 
1 V 2 to 15 years. In 16 there was suppuration; in 12, no suppuration. In 
19 cases no cause was found; in 8 cases a cause was given. Fenwick re- 
ports 76 cases: 4 children under 10 years, and 9 between 10 and 20 years, 
the 3'oungest being fourteen months old. Kustre makes a report of 230 
cases, 24 under 10 years of age, 17 between 10 and 20 years. Johnson, in 
an experience of nine years in Roosevelt Hospital, saw but one case in a 
child, a perinephritic abscess in a boy of 10 following a fall, not complicated 
by a kidney lesion. Israel, in a report of 43 cases, speaks of one in a 
patient 12 years old." 

Out of 3689 patients treated in the outdoor department of the Chil- 
dren's Hospital for the Belief of the Ruptured and Crippled, in New York, 
during 1894-1903, only 6 cases are reported by Townsend. 

Pathology and Bacteriology. — As a rule 80 per cent, of the primary 
cases terminate in abscess. In secondary cases an abscess is always found. 
The pathological condition is the same as is found in every acute inflam- 
mation. The pus contains either the streptococcus, the staphylococcus, or 
colon bacillus. In rare instances the pneumococcus and the typhoid ba- 



410 DISEASES OF THE KIDNEY AND BLADDER. 

cillus are present. In tubercular manifestations the tubercle bacillus will 
be found. 

Symptoms. — A child that has been in good health will suddenly de- 
velop pain in the region of the kidney near the vertebra. The pain extends 
downward and simulates sciatica. Moving the body increases the pain, 
hence the spine is generally rigid. For this reason alone many cases are 
mistaken for Pott's disease. There will also be fever, the temperature 
ranging between 102° and 104° F. If the child is old enough to complain, 
then chills will be noted. In the ileo-costal region there is usually a pal- 
pable tumor. Children so afflicted will refuse to walk on the affected side, 
and will limp. They describe the pain as though it were in the groin, in 
the hip, or sometimes in the knee-joint. If pyelitis complicates, the urine 
will contain pus. Owing to the passive condition there is constipation. 

A. B., 9 years old, complained of pain in the groin and also in the back on the 
left side. He limped and could not stand on his left leg. He complained of chills 
and his temperature rose to 103° F. He urinated very frequently. After a careful 
examination the urine was found to contain nothing abnormal. The boy was put to 
bed. The bowels were flushed. Owing to small roseolar spots which appeared, 
typhoid fever was suspected. The blood reaction for Widal was absent. The urine 
gave no diazo reaction. The pain increased, and after ten days of expectant treat- 
ment a swelling was noted in the loin. 

This swelling gradually increased in size until it was as large as a hen's egg. 
A surgeon was called who diagnosed perinephritis. An incision was made and two 
ounces of pus liberated. The wound was packed with sterile gauze, and with rest, 
iron, and strychnine internally, the boy recovered in about five weeks. 

Diagnosis. — This condition may be confounded with hip-joint disease, 
but hip-joint disease develops very slowly and has a tendency to become 
chronic. The symptoms, while very similar in perinephritis, develop sud- 
denly from within a few days to a few weeks, and recovery may occur within 
a few weeks after the first symptoms are noted. In hip-joint disease the 
symptoms extend over months and years. 

The Blood. — An important diagnostic point is the increase in the num- 
ber of leucocytes, such as we find in purulent conditions in other parts of the 
body. In tuberculosis there is no leucocytosis unless sepsis exists. 

Prognosis and Course. — Primary perinephritis runs an acute short 
course of a few weeks and usually terminates favorably. Gibney reports 
28 cases, all of which recovered. 

Treatment. — Rest in bed and a warm poultice over the affected area to 
hasten suppuration. The abscess should be treated on strict surgical prin- 
ciples. No time should be lost when fluctuation is felt, owing to the danger 
of pus burrowing into the peritoneal cavity. 

Restorative treatment, such as diet, fresh air, iron, and codliver-oil, 
should form the basis of the building-up process. 



PYELITIS. 



411 



Pyelitis (Pyelonephritis). 

This condition is rarely met with in practice. Literature records 
isolated cases. Monti, of Vienna; Baginsky, Steffen, and Holt are among 
those who have reported cases of this kind. 

Causes. — Pyelonephritis occurs at all ages, but is more common in 
adult males than in the young. The exciting causes in adult males are 
stricture of the urethra, renal calculi, prostatic diseases, and infection by 
means of dirty catheters. That girls seem to have been favored by this 
disease can be seen by referring to the literature; thus Professor Baginsky 
reports three cases, all girls, in the Deuisch. Med. Wochenschrift, 1897, 
Xo. 25, which he discussed at the Verein fur Innere Medicin in 1897. 
In these three cases the author was able to grow a culture of the bac- 
terium coli from the urine. He believes the bacterium coli to be the true 
etiological factor in this disease. In these three cases there were marked 
gastroenteric disturbances, in two cases membranous enteritis and obstinate 
constipation. In my case here reported there was severe constipation requir- 
ing constant treatment. 

Baginsky further maintains that the bacterium coli can enter the 
kidneys through: first, the circulation of the blood; second, the lymph 
channels; third, the urethra. 

Escherich, 1 Finkelstein, 2 and Trumpp 3 have reported a series of cases 
in which cystitis was found associated with intestinal affections. Baginsky 
reports two cases of pyelonephritis which could be attributed to the method 
of using gymnastics during orthopaedic treatment for the correction of con- 
genital dislocation of the hip joint. In connection with the exercises a 
direct invasion of the bacterium coli from the urethra to the bladder could 
be traced. Other authors, as Posner, believe that external influences have 
no bearing on the etiology, and that the infection takes place from within 
the body. It is a well-known fact that gonorrheal vulvo-vaginitis, espe- 
cially when it occurs in little girls, can cause either pyelitis or pyelone- 
phritis. This is termed the ascending variety. Chronic occlusion of the 
ureter may be followed by a pure pyelonephritis, without preceding cystitis, 
when the exciting agents of inflammation, which are present in the cir- 
culating blood, are eliminated through the kidneys and collect in the stag- 
nating urine in the pelvis of the kidneys. Experimentally this disease can 
be produced in rabbits by ligating the ureter and injecting either bacterium 
coli or pyogenic cocci directly into the pelvis of the kidney or into the 
veins. 



l Mittheil, d. Vereins der Aerzte in Steiermark. 1894. 

2 Finkelstein. Jahrbuch f. Kinderheilkunde, Band xliii, page 148. 

3 Trumpp. Ibid., Band xliv, page 249. 



412 



DISEASES OF THE KIDNEY AND BLADDER. 



Pathology. — -Increased pressure in the tubules from obstruction to the 
escape of urine; reflex irritation of the kidney; the presence of septic 
matter in the pelvis of the kidney and possibly in the lower parts of the 
tubules. Most frequently these three causes act, in succession and in the 
above order, in the same case. As a rule, when acting singly, increased pres- 
sure from obstruction will produce hydronephrosis; reflex irritation will 
excite one of the transient or congestive types of urinary fever; and septic 
matter in the pelvis of the kidney will cause acute or suppurative pyelone- 
phritis. Increased urinary pressure alone often produces chronic inter- 
stitial nephritis as well as sacculation and dilatation of the kidney; but it 
rarely, if ever, causes acute or subacute interstitial nephritis. Decompo- 



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Fig. 121. — Fever Curve in Pyelonephritis. (Original.) 



sition of urine in the bladder or pelvis of the kidney may produce suppura- 
tive changes in the kidneys. If the dilatation of the kidney is not compli- 
cated by suppurative pyelitis hydronephrosis results. If it is so compli- 
cated, pyonephrosis is produced. Klebs and others believe that bacteria have 
migrated to the pelvis and calices of the kidney, there to produce their 
destructive changes, hence the names of parasitic nephritis and pyelo- 
nephritis as proposed by Klebs. 

Lindsay Steven in a thesis on the pathology of the suppurative inflam- 
mations of the kidney, published in the Glasgow Medical Journal, Septem- 
ber, 1884, corroborates Ivlebs's view and expresses a decided opinion that 
micro-organisms are at the root of the infection, and cause the formation 
of multiple renal abscesses consequent on diseases of the lower urinary 
passages. He, however, considers that there are two ways wdiereby the par- 
ticular virus gains access to the kidney and sets up suppuration in many 
different points, namely : first, by means of the uriniferous tubules, and 
second, by means of the lymphatics of the ureter and kidney. 



ECTOPIA VESICA CON". KM TALIS. 



413 



Steven show- that the lymphatics, quite independently of any other 
channel, may form the pathway of the virus from the bladder to the kidney. 
He admits that the two ways may be more or less combined in many cases; 
so that multiple miliary abscesses may originate in the same kidney, partly 
by the invasion <>( micrococci along the ureter and uriniferous tubules, and 
partly by their inroad along the lymphatic tracts of the kidney. 

Traube and others who do not think that the bacteria themselves 
excite the inflammation, consider that these organisms cause the decom- 
position of urea into carbonate of ammonia and that this in turn excites 

inflammation of the mucous memhrane of the kidney. 

Prognosis. — The prognosis is grave and depends on the toxin caused 
by the presence of the pus. The outcome of the case depends on the dis- 
appearance of the pus in the urine, which must be watched for at times. 

Treatment. — A child suffering with pyelitis should be put to bed in 
a cool room having plenty of fresh air and sunlight. 

Dietetic treatment such as milk with some alkaline water is useful. 
Xo solid food should be permitted. Whey, soups, broths, and fruit juice? 
may be given. Oranges and lemons, owing to their diuretic effect, are 
valuable. The internal use of Eoncegno water or Wildungen water is also 
recommended for its diuretic effect. 

Diuretin. in 2 to 10-grain doses three times a day, is sometimes useful. 
Urotropin is a very valuable drug and serves both as a diuretic and as an 
internal antiseptic. 

The Bladder. 

The bladder takes up almost all of the lower portion of the abdomen, 
as it is capable of marked distention when filled. To make proper physical 
examination the bladder should be emptied by catheter. 

Botch refers to a distinguished laparotomist who did not empty the 
bladder of a child before operating for an appendicitis: on opening the 
abdominal cavity he cut directly through the walls of the bladder. The 
urine flowing out reminded him of his failure to appreciate the fact that 
in early life the bladder is essentiallv an abdominal organ. 



Ectopia Vesicae Coxgexitalis (Extroversion oe the Bladder: 
Exstrophy of the Bladder). 

This anatomical peculiarity is due to deficient closure of the neutral 
•lamina:' causing this hiatus of the abdominal wall in some cases. "The 
lower part of the abdominal wall, from the umbilicus or its neighborhood 
downward, may fail to close, and. coupled with this, there may be deficiency 
of the anterior wall of the bladder." This constitutes extroversion, some- 



414 



DISEASES OF THE KIDNEY AND BLADDER. 



times called exstrophy of the bladder. The ureters are plainly visible ami 
the urine dribbles continuously. The child is constantly wet and excoriated 
from the moisture and its irritation. The urine is passed in distinct jets 
or streams, and is especially noticeable when the child cries or strains. 

The following case was presented by me to the children's clinic of the 
New York Post-Graduate Medical School and Hospital. 1 

A female infant, 1 year old, was seen by me. She was breast-fed and well- 
nourished. Soon after birth the mother noticed a constant dribbling of urine and 
attention was directed to a swelling situated in the region of the umbilicus. The 




Fig. 122. — Exstrophy of the Bladder, and Prolapse of Anus. (Original.) 



diagnosis of exstrophy of the bladder was made. A bland ointment was prescribed 
to relieve the excoriation from the constant dribbling of urine. As this case 
required a plastic operation it was referred to Dr. Carl Beck, at the St. Mark's 
Hospital, for surgical treatment. 



1 This case was also presented by me at the Scientific Society of German Phy- 
sicians held at the residence of Dr. A. Jacobi about ten years ago. 



I'NTUIA. 



415 



A child in this condition should not be operated upon until ;> or 4 
years of age. 

Indicanuria. 

A trace of indican is found in the urine in health. A very strong 
indican reaction should always be regarded as abnormal and hence it is 
pathological. As indican is derived from indol it signifies a product of 
decomposition and denotes putrefaction of the proteids. It lias also been 
Pound in empyema and in extensive suppurative processes where putrefac- 
tion abounds. Stagnant faeces, constipation, chronic intestinal indigestion, 
and some Conns of putrefactive diarrhoea will give a strong indican reaction. 
I Idler has reported the presence of indican in the urine in cases of 
epilepsy at the time of the seizures. In the early stages of typhoid fever, 
when the diagnosis is doubtful, the presence of a Diazo reaction and the 
absence of indicanuria is a valuable aid in the diagnosis. 

Eliminative treatment such as cleansing the gastro-intestinal tract, 
besides reducing the amount of meat and eggs, will relieve an excess of 
indican (see article on "Intestinal Indigestion"). 

ACETONURIA. — DlACETOXUKIA. 

We are indebted to Baginsky for a careful study of this condition. He 
found that it was present in children during epileptic attacks. It is also 
found during the height of fever. He does not believe that acetonuria bears 
any relation to the nervous symptoms which accompany fever. 

Diacetonuria is very common during high fever. It is more frequently 
present than acetonuria. Binet, quoted by Holt found diacetic acid in 
sixty-nine out of one hundred and fifty examinations in febrile diseases, 
chiefly in scarlet fever, measles, and pneumonia. 



Pyuria. 

When pns is found in the urine, it gives a reaction like albumin, namely, 
coagulates on boiling. Pus cells, however, can be seen only by placing a 
drop under the microscope, using low power. While pus usually indicates 
pyelitis or pyelonephritis, it may exude from the ureters, the bladder, the 
urethra or the vagina. 

Tubercular or suppurative conditions affecting the spine associated with 
caries of the spinal vertebrae may drain into the urinary tract. It is 
important, therefore, to locate the cause before treatment is commenced. 

Pus from the bladder is always mixed with mneus. It may be acid or 
alkaline in reaction. The urine containing pus due to pyelitis has an acid 
reaction. If the child is old enough, a cystoscopic examination should be 



416 DISEASES OF THE KIDNEY AND BLADDER. 

made. This will aid in excluding the bladder and the ureters as a possible 
source of the pus. 

Treatment. — Demulcent drinks, alkaline waters, such as the TVildungen 
water, have a mild, diuretic effect. Salol and urotropin are the best drugs 
in doses of two to five grains three times a day. Milk, cereals, and fruits 
should be ordered; meat and eggs prohibited. 

Diabetes Insipidus (Polyuria). 

This is a very rare condition in children. Its etiology is obscure 
although males are more frequently attacked than females. Little is known 
of its origin excepting that traumatism involving the brain has been known 
to be followed by diabetes insipidus. 

The pathology of this disease is unknown. It is supposed to be a 
neurosis but whether the lesion is near the fourth ventricle, or whether its 
seat is in the renal nerves, has not yet been determined. 

Symptoms. — Excessive thirst and an excess of urine constitute the main 
symptoms. From five to ten pints or even more may be passed in twenty- 
four hours. The urine looks like water and has a specific gravity from 
1001 to 1005. In some cases mosite (muscle sugar) has been found (Holt). 
Albumin and grape sugar are not found. Urea is excreted in large quan- 
tities, whereas uric acid is not. Eestlessness by day, headache, insomnia, 
and marked irritability are the chief symptoms. Unilateral flushes of the 
face, and one ear, and similar vasomotor disturbances are present. There 
is an absence of perspiration. The skin is dry. Development is retarded, 
especially growth. The appetite remains good. The temperature may be 
subnormal. 

' Prognosis. — The disease has been known to last years. Some cases 
recover spontaneously. As a rule it is wise to give a guarded prognosis. 
Cases of diabetes insipidus are very susceptible to other diseases and usually 
die from some complication. 

Treatment. — A very nutritious diet consisting of milk, meat, eggs, and 
fruit with some restriction as to the quantity of liquid should be made. 
[Restoratives such as Fowler's solution, iron, and cod-liver oil will sometimes 
do good. "When marked nervous symptoms exist, then atropine, Dover's 
powder, belladonna and the bromides may be tried. Change of air such as 
an ocean voyage or mountain air may be of benefit. 

Lordotic Albuminuria (Orthostatic Albuminuria). 

Heubner has directed attention to the presence of albumin in the 
urine when children are standing erect. The albumin disappears when the 
child assumes a horizontal position, hence albumin will be present by day, 
and will disappear in the urine voided at night. 



H.KMATl MA. 417 

Jehle, \ una. i:i his monograph published ii 

•n uion b la a different cause f<»r t - >f the 

albumin in the urine. He finds that when lordosis is present, and in 
sequence the lumbar vertebrae offend the kidneys by displacement 

sure, that albumin will at once appear in the urine. That this is no theory 
he shows by producing an artificial lordosis. When in the dorsal p - 
albumin will be found in the urine and disappear when such pressure i- 
removed. This presence of albumin is found in normal kidneys in which 
no previous scarlatinal or other forms of nephritis have existed. It i-. 
therefore, a mechanical type of albuminuria which can be made to appear 
durin_ - s and to dig when the lor sis is 

Hematuria i Bloody Urine). 

Hematuria is known by the presence of red blood-cells in the urine. It 
e due to local irritation or to systemic disease. It is therefore fre- 
quently met with during the course of a severe attack of acute nephritis, 
complicating scarlet fever. A case of this kind is reported in the cb ter 
."I have freqiici _: hematuria during the course 

e hemorrhagic form of diphtheria, while on duty at the Willard 
tal. I have also seen hematuria in scurvy. 

nt to remember that irritation caused by a calculus in 
the k: ter, or the bladder may give rise to bloody urine. I 

injury to the kidney or bladder, or a tumor in the bladder, may 
bloody urine. 

causes j are hemorrhagic dise ses 

the new-born: the blood dyscrasia?, such as scurvy, purpura, and hemo- 
philia: and infectious -. particularly tvphoid, variola. ~ - 

and influenza. In most of thes : ises the amount of blood j - 
- = ill. When it i s I i _ e it may appear in the urine as clear blood or as 
»r it may impart simply a reddish or smoky color to the urine. 
rever, is not guide; the best of all is the mi 

exam test g ;um may be us 

a a difficult matter to discover the source of blood in some 
although large hemorrhage is more a^ suit from the kid: 

from the bladder. To diff we must rely on the presence of 

from the renal tul n satisfy ourselves of the renal 

hemorr _ 
The prognosis le] mds on the amount of hemorrhage and the general 
condition of the child. It should alw: - _ 

v fatal. 



418 DISEASES OF THE KIDNEY AND BLADDER. 

Treatment. — The application of an ice-bag or dry cnps over the region 
of the kidneys, rest in bed, SquibVs ergot, gallic acid, 3 to 10 grains, 
repeated every three or four hours, or the fluid extract of Hydrastis cana- 
densis, in 3 to 10-drop doses, for a child 2 years old, repeated every three 
or four hours, will sometimes do good. 

The food is best given either cool or very cold. If the child is old 
enough, small pieces of cracked ice or ice cream may be given until the 
blood disappears. 

HEMOGLOBINURIA. 

Instead of blood cells in the urine this condition manifests itself by 
the presence of blood pigment in the urine. Sometimes the urine is blackish. 
Albumin may frequently be found associated with haemoglobin. The 
pathology of this condition is at present unknown. It is very easy to 
recognize the pigment under the microscope. It can also be noted by 
Heller's test. The most positive method of diagnosis is the spectroscope. 

Not infrequently this condition is met with in the infectious diseases, 
which is evidently due to the effect of the toxins generated by the specific 
micro-organisms causing these diseases. When an irritant poison, such as 
carbolic acid, is swallowed, this condition is encountered and recognized, 
clinically, by the familiar term "smoky urine." 

Paroxysmal haenioglobinuria is occasionally met with in childhood. 
It is usually associated with syphilis. Other cases have been reported. 1 

Glycosuria. 

The appearance of sugar in the urine is not necessarily pathological. 
Grosz published a series of investigations dealing with this condition. He 
found that glycosuria occurs in nursing infants who have either functional 
or inflammatory disturbances of digestion. He did not see it in perfectly 
healthy nursing infants. The sugar found in the urine reacts to Fehling's 
test; it does not respond to the fermentation test. The polariscope shows 
that it has the power of dextro-rotation, so that the sugar present is pos- 
sibly milk sugar or one of its derivatives. 

Artificial glycosuria can be produced by administering a large quan- 
tity of milk sugar in the food, hence it may be presumed that trie sugar 
excreted in the urine is simply the excess of what could not be absorbed in 
the system. 

Glycosuria was frequently noted by me in the urine of children fed 
exclusively on Xestle's food. When this form of feeding was discontinued, 
the glycosuria disappeared. These cases could therefore be classified under 
the head of dietetic glycosuria. 



i Archives of -Pediatrics. 



( OLM VST] HS. 



•II!) 



Diabetes M ellitps. 

9 of this nature are frequently mel with in children. The pathol- 
ogy is as yet rather dark. Of the etiological factors heredity must cer- 
tainly be considered. Parvy reports the case of a child. 2 years old, that 
died of diabetes, in whose family the disease had ex i ted for several gen- 
eral 

Symptoms. — Sugar in the urine, excessive thirst, emaciation, acetonuria, 
and polyuria are the most important symptoms. 

this kind was seen by me in consultation with Dr. 1>. Brodski of New 
York City. A girl, about 10 years old. suffered with excessive thirst. She could drink 

several pints of water in sucees>ion. and still complain of thirst. In the same 
manner she passed many times more pints of urine than would he normal. The, 
appetite was poor. The child complained of extreme weakness and showed signs of 
emaciation. Sugar and acetone were found in the urine. In spite of restorative 
treatment the case ended fatally. 

Equally instructive were two cases seen by me at the children's service 
of the German Poliklinik. They occurred in the practice of Dr. L. F. W. 
Haas. They were reported in extenso to the Section on Diseases of Children 
at the meeting held at Atlantic City in June, 1900. 

Prognosis. — The prognosis is always grave. When the urine contains 
diacetic and oxybutyric acids the condition is more serious than when the 
urine contains sugar alone. 

Boughly stated, the duration of the disease may be about six months, 
although some children linger for years. 

Treatment. — In the diet milk and cereals are most important. Cod- 
liver-oil, iodide of sodium, and Fowler's solution are beneficial. General 
hygienic measures, such as sending the child from the city to the country or 
to the seashore, may be of benefit. 



COLICYSTITIS. 

We are chiefly indebted to Escherich for calling our attention to this 
condition. 

Bacteriology and Pathology. — The bacterium coli commune gives rise 
to this condition. The bacteria can migrate through the female urethra 
and set up a cystitis. When the intestinal mucous membrane is not intact, 
as, for example, in catarrhal enteritis, these bacteria can enter the bladder 
by misrratincr through the intestinal mucous membrane. 

Symptoms. — There is fever and irritability of the bladder shown by 
tenesmus. The urine contains pus, sometimes traces of albumin, and has a 
very foul odor. As a rule the urine is milky or cloudy, or it may be dark 
in color. In some cases there may be vomiting and headache associated with 
pains in the bladder and in the back. 



420 DISEASES OF THE KIDNEY AND BLADDER. 

Prognosis. — The prognosis is good. 

Treatment. — Internally, 3 to 5 grains of urotropine, several times a 
day, or oleum gaultheria, 1 to 3 drops, three times a day, or salol, 3 to 
5-grain doses, three times a day, may be given. 

Locally. — The bladder should be washed with a double current catheter. 
A weak permanganate of potash solution should be used, 3 or 4 ounces 
being injected at one time; this should be continued until several pints 
have been used. In some cases irrigations of a bichloride of mercury solu- 
tion, 1 to 4000, repeated several times a day, may be useful. 

Urethral Calculi (Vesical Calculi: Stoxe in the Bladder). 

This condition is extremely rare in infancy. It is not so rare in chil- 
dren after the third year owing to their solid diet. Stone in the bladder 
is usually composed of uric acid, and is often the result of uric acid in- 
farction in the kidney. In this condition calculi pass from the pelvis of the 
kidney through the ureters and lodge in the bladder. 

Symptoms. — While urinating there will be a sudden cessation of the 
flow of urine. Pain either in the penis or in the perineum is sometimes 
described. As has been described (in the chapter on "Cystitis") whenever 
severe tenesmus exists causing prolapse of the rectum without definite in- 
testinal trouble, we should suspect trouble in the bladder. Incontinence of 
urine is sometimes present. 

Diagnosis. — If the child is old enough a diagnosis can sometimes be 
made by insertiDg one finger into the rectum and pressing over the bladder 
in the abdomen (bimanual examination). Although this method of bi- 
manual palpation is frequently valuable, it sometimes gives negative re- 
sults. The surest method is to explore the bladder with a sound. In very 
sensitive children cocaine may be injected into the urethra before the sound 
is passed. In exceptional cases, only with the aid of an anaesthetic, can 
a positive diagnosis be made. 

Treatment. — Such cases should be treated by the surgeon, although an 
attempt at crushing the stone might be made. The radical operation of 
supra-pubic lithotomy may be necessary. 

Very large calculi have been seen by me in the Stephanie Children's 
Hospital, in Buda-Pest, through the kindness of Prof. Johann von Bokai. 
Professor Bokai told me that from certain districts in Hungary they 
receive many cases of large vesicle and urethral calculi. It is therefore 
quite evident that the calculi are intimately associated with the geographical 
, conditions favoring the same. 

Acute Cystitis. 
This condition is seldom seen in children. 



CHRONIC CYSTITIS. 421 

Etiology. — It is most usually due to the invasion of pathogenic bac- 
teria, such as the bacterium coli and the gonococcus. 

It is most frequently the result of an extension of an infection from 
the external genitals through the urethra into the bladder, so that blenor- 
rhcea in children may be an exciting cause of acute cystitis. It has also 
been known to arise from typhoid bacilli eliminated through the kidneys 
by the urine. 

Stone in the bladder and intestinal irritants, such as turpentine or 
copaiba, have been known to cause cystitis. 

Females are more prone to this affection than males. 

Symptoms. — Very frequent desire to urinate, accompanied by pain on 
urination, is the principal symptom. The urine has a reddish color, but 
later in the disease has a light color. Its specific gravity is high. The 
reaction of the urine is alkaline. On standing there is a thick sediment 
consisting of mucus, pus, and blood. Microscopically, there are pus cor- 
puscles, squamous epithelium, and blood-corpuscles. In females it is neces- 
sary to use a catheter in drawing off the urine to obtain a specimen for 
examination, as the epithelium of the bladder and the vagina are strikingly 
similar. 

Prognosis. — This is invariably good. 

Treatment. — Bladder washing with mild antiseptic solutions, such as 
a 1 per cent, boric acid or bichloride, 1 to 5000, or a weak permanganate 
of potash solution, is useful in some cases. Alkaline waters, such as the 
White Rock, Lithia, or Appollinaris in large quantities should be given. 

Internally the diet should be regulated so that the child receives milk 
and Seltzer, thin soups and broths, fruit and fruit juices. Meat and all 
spices must be avoided. Only bland articles may be permitted. 

Drug Treatment. — Urotropin, in doses of 5 to 10 grains, several times 
a day, is very beneficial, or Dover's powder, 1 or 2 grains, several times a 
day, will do good. In very high fever an ice-bag can be applied over the 
bladder. 

Chronic Cystitis. 

This condition is usually associated with a malignant growth in the 
bladder, such as a tumor, or frequently by stone in the bladder. It may 
also be due to a general tuberculosis with special local manifestations in 
the bladder. The composition of calculus is mainly uric acid, with large 
quantities of phosphates from the alkaline urine. 

Symptoms. — From the constant dribbling of urine the child will have 
an offensive urine smell resembling ammonia about him. 

There is an irritation around the external genitals, due to excoriation 
from the moisture. If stone is the cause of this condition the urine will 
be interrupted while passing and the child will complain of pain. The 



422 DISEASES OF THE KIDNEY AND BLADDER. 

pain is difficult to localize, although it is described as being at the end of 
the penis. Girls will localize the pain at the meatus. From severe tenesmus 
there may be prolapse of the rectum. 

The urine resembles the urine of an acute cystitis. Tubercle bacilli are 
found in bladder tuberculosis. 

Prognosis. — This depends upon the condition of the child and on the 
cause of this affection. A cautious prognosis is necessary in tuberculous 
affection, or if a tumor exists. 

Treatment. — If a stone is present the treatment is surgical. Uro- 
tropin and salol are very valuable, and I have seen permanent benefit from 
their use. 

B Sodium sulpho-carbolate 25 grains 

Sig.: Divide into 5 powders. One powder every three hours in an alkaline 
water, is also beneficial in some cases. 

Bladder washing and the diet as described in the article on "Acute 
Cystitis" should be employed in chronic cases. 

When there is a general atony of the body then this condition will fre- 
quently result in the weakening of the sphincter vesicas muscle or in the 
spasm of the detrusor urinse muscle. Other conditions causing enuresis 
are lithiasis vesicalis, and where stones are suspected the bladder must be 
very cautiously inspected. 

Children that convalesce from a severe form of disease, such as typhoid 
fever or any long existing febrile disorders, will usually have enuresis as a 
result of a general breaking down of the body wherein the muscles lose 
their tone. 

Other conditions causing irritation may be enumerated as congenital 
phimosis or adhesions of the prepuce, strictures of the urethra, also irrita- 
tions from worms, such as ascarides, commonly known as pin-worms ; fis- 
sures of the anus; frequently also in older children, masturbation and 
vulvitis may be considered as possible causes of this condition. (Read 
chapter on "Lithuria") 

Calcareous deposits in the kidneys or stone in the bladder, the over- 
loading of the urine with lithates or phosphates, have frequently caused 
abnormal irritations resulting in enuresis. 

Enuresis. 

An involuntary emptying of the bladder during the day is known as 
enuresis diurna. When this condition exists at night it is known as enu- 
resis nocturna. 

Causes. — (a) Organic; (b) functional. 

Organic Causes. — Any inflammatory condition involving the urethra 
or bladder, or diseases of the brain or spinal cord, frequently cause this 
condition. 



ENURESffi. 423 

mich 1 considers this condition, when occurring in a child who 
has been clean for months or years, and who shows no sign of organic dis- 
ease of the urogenital or nervous system, as a sign of that general neurosis, 

ria. In children hysteria usually occurs in a monosymptomatic form. 
The children who suffer from enuresis at some period usually come of a 
neuropathic family, and later show some other symptoms of hysteria. 

Functional Causes: Adenoids. — It is not infrequent to find that ob- 
structions of the nose and in the naso-pharyngeal spaces can cause enuresis. 
One of the most frequent causes met with is adenoids. It is a safe rule to 
examine the pharyngeal vault when enuresis exists. My e: e has 

been that over 50 per cent, of the cases of enuresis seen in my clinic have 
adenoid vegetations. 

Tight Prepuce. — If other irritations, such as a tight prepuce exist, 
then circumcision must be insisted upon. If irritation exists in the urine 
on account of an excess of lithates or phosphates, then internal treatment 
must be directed toward relieving this condition. (Bead article on '\Lith- 
amiia 

Prognosis. — The prognosis of this condition is usually good. In ob- 
stinate cases it may be valuable to insist on a change of air ; thus, removing 
the patient from the city to the country or to the seashore is of value in 
some severe cases. 

Treatment. — A very bland, non-irritating diet, consisting of cereals 
and milk, will be indicated. All spices, alcoholics, coffee, and. tea must be 
prohibited. Do not permit liquids to be taken before retiring. It is alsc 
important to have the bladder emptied immediately before retiring. 

Drug Treatment. — One of the best drugs is strychnine in doses of 
Vioo & ra i n ? three tin:-;- . gradually increased. In addition thereto 

small doses, V 10 grain, gradually increased, of the extract of belladonna. 
When a general atony exists then nothing will be better than iron given in 
the form of elixir of quinine, iron, and strychnine. Massage and gentle 
n of the whole body, cold sponging, especially of the spine, are valu- 
able adjuvants to the treatment of this condition. A cold douche directed 
to the spine, especially to the lumbar region, will be found of great assist- 
ance. 

Fowlers solution and iron are very valuable in weak children. 

For incontinence of urine, internally may be given: — 

R Ext. rhus. aromaticte, fl 10 mining 

Syrup aromatiei 20 minims 

Aq. destillatae. ad 1 drachm 

Sig. : This amount to be given three times a day. 

Or:— 



Berl. Klin. Woch., vol. xxxviii, Xo. 31. 



424 DISEASES OF THE KIDNEY AND BLADDER. 

B Liq. atropinae sulphatis 1 V» drachms 

Liq. strychninae hydrochloratis 45 minims 

Syr. aurant ad 1 ounce 

Sig.: For a child 14 years old, 5 drops at night; increase gradually. Younger 
children in proportion. 

The Use of Electricity. — Faradic electricity applied over the bladder, 
and also over the lumbar region of the spine for several minutes every day, 
and gradually decreased to every two or three days, is of value in some 
cases. 

According to Thiemich, excellent results are obtained by means of pain- 
ful faradization, not necessarily of the sphincter vesicae, but of the arms, 
back, or thighs. Care should be taken to prevent the impression that the 
treatment is a punishment, but instead it should be explained that the 
measure is certain of success, even though painful. More than one appli- 
cation is rarely required if care and tact be exercised. As in all forms of 
hysteria, isolation and removal from home are the most potent of all 
remedies. 

Mechanical Treatment. — The passage of cold sounds and dilatation of 
the urethra by this means is sometimes very effectual. Elevating the foot 
of the bed is of value in some cases. The child should not be allowed to 
sleep on its back. To prevent this position it is advisable to tie a towel 
around the child's body so that the knot is in the center of the back. This 
will awaken the child if it turns on its back and will compel it to sleep on 
the side. 



PART VI. 

DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 

DISEASES OF THE NOSE AND THROAT. 

Acute Nasal Catarrh (Rhinitis, Coryza). 

Infants sneeze normally during the first few days of life, the me- 
chanical irritation of dust in the air being the cause of the same. The 
great difference between the intrauterine temperature and the temperature 
of the air renders the new-born baby sensitive and invites respiratory 
catarrh. 

Etiology. — Pyogenic bacteria are certainly the cause of the disease. 
They will be found in the nasal discharge. 

Rachitic infants are more prone to nasal catarrh than others. It is 
most likely contagious. Several children in the same family will have the 
disease at the same time. The handkerchief can no doubt carry the con- 
tagium from one to the other. 

Children in mauy families have a predisposition to catarrh. There 
are two great extremes: — 

1. Children that are kept indoors and muffled up so that their bodies 
are overheated, are very sensitive to exposure, and will have nasal catarrh 
if exposed to a draught. 

2. Those children who, in order to be "hardened," are over-exposed 
when their skin is still sensitive. 

Symptoms. — There is a hyperemia in the nasal passages causing ob- 
struction. This will compel the infant to breathe through the mouth. 
Where nasal catarrh exists there is always an interference with the feeding. 
The nose being stuffed, the infant must breathe through the mouth. There 
is usually a slight elevation of temperature. The secretion which at first 
is thin and mucous, later on assumes a muco-purulent character. This 
latter dischargers thick and sticky, and while drying obstructs the nostrils. 

Persistent catarrh calls for an exploration of the vault of the pharynx 
and suggests adenoids. If present, no other treatment but their removal will 
remedy the catarrh. 

Diagnosis. — Acute nasal catarrh must not be confounded with syph- 
ilitic rhinitis. The history should be carefully noted. Rhinitis is one of 

(425) 



426 DISEASES OF THE NOSE AND THROAT. 

the earliest symptoms of measles, hence the buccal mucous membrane should 
always be examined for the presence of an enanthem. 

If the temperature is high — 102° to 103° F. — and there is an eruption, 
then the possibility of measles should not be overlooked. In all ea* 
measles the pharynx and tonsils should be carefully examined. Diphtheria 
of the pharynx frequently has an acute rhinitis associated with it. Per- 
tussis is very often preceded by rhinitis. Inflammation of the lachrymal 
duct is at times associated, causing acute conjunctivitis. Sometimes the 
inflammation will extend through the Eustachian tube and cause otitis. 
In older children deafness is frequently caused by closure of the Eu- 
stachian tubes. 

Treatment, — Hygienic Treatment'. Put the child to bed if there is 
fever, but if the temperature is normal then keep the child indoors in a 



Fig. 123. — Atomizer. 

room with a temperature of Tv c F. The body should be warmly clad after 
having been given a good tub bath, followed by friction with a coarse 
Turkish towel. 

Ehinitis tablets, containing the following ingredients, for the prophy- 
lactic and general treatment of catarrh of the nose and throat, have ien 
used by me : — 

R Soda salicylate 1 grain 

Tinct. aconite 1 minim 

Tinct. belladonna \ i: minim 

The above quantity is for one tablet. 

One tablet can be given with water every three or four hours to a child 2 
years old; smaller children in proportion. 

Medicinal Treatment. — The gastro-intestinal tract requires cleansing. 
A drachm of castor-oil at the commencement of treatment is beneficial. 
The best drugs are quinine and belladonna given internally. The quinine 
chocolates, 1 grain of quinine, can be given to a child 1 year old; : 






>AL < ATARRH. 



427 



infant six months old one-half the d ee. Fluii 

j minim, three times a day. Salol tablets, _ '. _ 

_ en with 

.--A solution of adrenalin 
be us - strils in very y _ ts. In older children a 

solution of 1 - same purpose. 

The discharge can also be removed by irrig i • :tli a 1 per 
boracic acid or boras solution or a 1 pe salt 8 utain- 

_ - >me glycerine, with an atomize - _ L23) or with Letferts* \ - - 




Kg. 124. — Lefferts' Posterior and Anterior Nasal Syringe. 

rior and anterior nasal syringe, followed by an alboline spray. The fol- 
lowing prescription is useful for the nasal toilet : — 





: , ounce 


Table salt 


1 drachm 


Borax 


1 drachni 


Water 


8 ounces 



- a combination containing the ss tial oils of thyme, 
eucalyptus, baptisia. gaultheria, and mentha arrens - 

Other valuable preparations using the naso-pharyngeal s] - 

's = ition. borolyptol. md Sei r's solution. 



l's S : c 



B Sodium bibo: 

Sodiimi bicarb 

Give, of carb. acid 
Water to m; 



1 drachm 

1 drachm 

2 drachms 

int 



Borolyptol contains 5 per cent, aeeto-boro glyceri nt. for- 

maldehyde, in combination with the active antiseptic constituents of pinus 
pumilio. eucalyptus, myrrh, storax, and benzoin. 

very bland, mildly astringent solution adapted for the 
pharynx. I frequently use this solution as a menstruum for carbolic 
or bichloride. All solutions used in the nose should be non-irritant, 
caust 3 should led. 



428 



DISEASES OF THE NOSE AND THROAT. 



Seiler's Solution. 

Sod. bicarb ., 1 ounce 

Sod. biborate 1 ounce 

Sod. benzoat 20 grains 

Sol. salicylate 20 grains 

Eucalyptol 10 grains 

Thymol 10 grains 

Menthol 5 grains 

Oil of gaultheria 6 drops 

Glycerine S 7a ounces 

Alcohol 2 ounces 

Water to make 10 ounces 



Tablets sold in shops under the name of Seiler's tablets can be dis- 
solved in 4 ounces of water. They are of the same strength as the solution 
here mentioned. 

Cocaine and eucaine, which are so valuable in adults, should not be 
used in children. In older children the inhalation of equal parts of tincture 
of iodine and aqua ammonia every half-hour will frequently abort the 
disease. 

Dietetic Treatment. — The nursing infant should be fed at regular 
intervals. If bottle-fed the same regularity 
should be observed. No stimulants should ^!T>^_ 

be given. It is unwise to give codliver-oil 
or other restoratives when radical treatment 
is called for. 





Fig. 125. — Lenox Nasal Douche. 



Fig. 



126.— Graduated Douche Suit- 
able for Older Children. 



Nasopharyngeal Catarrh — Frequently Causes Gastric Catarrh. 

The association of naso-phanmgeal catarrh with catarrh of the stomach 
may at first, seem peculiar. When, however, the anatomical relationship 
of the mucous membrane of the naso-pharynx with the oesophagus and 
stomach are considered, an extension of the disease can easily be understood. 
There are certain points which have a decided bearing on the etiology of 
gastric catarrh when caused by naso-pharyngeal disease. Such are: — 



FOREIGN BODIES IN THE NOSE. |_>'.» 

1. The fact that children rarely, infanta never, expectorate. When 
they have post-nasal catarrh and there is an irritation from mucous or muco- 
purulent secretion infants invariably swallow the same. It is for this 

reason that the old-fashioned dose of ipecac or castor-oil was given, not to 
relieve the cough nor to hasten the expectoration, but rather to cleanse the 
stomach from non-expectorated secretion. 

3. Loss of Appetite. — The loss of appetite, usually associated with se- 
vere oaso-pharyngeal catarrh in which the stomach has been normal up to 
the beginning of the attack, is usually due to the swallowing of large quan- 
tities of this infectious secretion. 

The benefit derived from curing a cold with a dose of castor-oil simply 
means removing some of the swallowed muco-purulent secretion from the 
stomach which should have been expectorated. 

"When catarrhal disease affecting the naso-pharyngeal space is muco- 
purulent and. continues for a long time in very young infants, w T e can easily 
see why the loss of appetite may be the means of causing deficient nutri- 
tion. Such cases may end fatally. The importance of attending to diseases 
in the naso-pharynx can be seen when it is considered that diphtheria can 
spread from the pharynx to the oesophagus, and also to the stomach. 

While it is true that diphtheritic gastritis is reported very rarely, it is 
well to bear such cases in mind, for they show the great danger to the 
stomach from an infectious catarrh located at the food entrance. There 
is usually a deficiency of hydrochloric acid secretion in all severe catarrhal 
diseases. This is most apparent in those febrile conditions which accom- 
pany diphtheria. It is for this reason that it is not very difficult for the 
stomach to be the seat of an infection if diphtheritic membrane is swal- 
lowed. 

It is of the greatest importance to have every child's throat in a nor- 
mal condition. Adenoid vegetations and diseased tonsils favor the devel- 
opment of malignant disease. The vast majority of patients who are 
infected with diphtheria, owe this infection to the diseased state of their 
throat, which favors the development of pathogenic bacteria. This can 
as easily be verified in children as in adults. It is rare to find a case of diph- 
theria in which a previous normal throat existed. Hence it would seem 
plausible to eradicate all trifiing as well as serious nose and throat disease, 
and aim to secure a healthy state if ire are to ward off infections. 

Foreigx Bodies ix the Xose. 

Children frequently while playing with beans, beads, shot, etc., stick 
them in the nose. If allowed to remain they frequently become encrusted 
with carbonate and phosphate of lime. Then it is knowm as a rhinolith. 
An angular forceps or a polypus forceps has frequently dislodged these 



DI- rOSE AND THEuAT. 

foreign bodies. A nasal irrigation into the unobstructed nostril will sonie- 
:. removing the f _ dv. 

TOXSELLITI- ._ IAREHALI- 

This is an aente inflammatory lesion, undoubtedly due to the infeo~ 
of the strnctnres of the tonsil by micro-organisms which enter the lacuna? 
or lymph chann^- 

iteriology and Pathology. — The tonsils 1 are lymphoid s truer 
resembling Peyer's patches of the small intestine. Various species 
of cocci and bacilli are to be found within the lacuna?, within the 
follicles, and even within the epithelial cells of tonsils removed duriL_ 









- 



I _ 1_ . — Angina Tonsillaris. Met hvlene-bhie Staining emersion 1-12. 

Ocular 4. Aftei "ager. Klin. Mieroseopy. > 

Leucocytes in large numbers are found associated with the microbes. 

During the presence of inflammatory conditions, such as the presence 
of the ntaghnn of diphtheria, desquamation of the epithelial covering 
takes place. This proliferation of the cells seen in diphtheria may entirely 
denude the tonsils of its epithelial covering in places. Thi? will then per- 
mit any specific virus to be brought into contact with the lymphatics and 
then be carried into the general circulation. TYe see an acute inflammation 
of the ton in -arlet fever, in measles, and in diphtheria. It may 
t seen in other infectious diseases, sc also in acute inflammatorv mani- 

tions. 

Symptoms. — One of the most frequent diseases of infancy and child- 
hood is tonsillitis. TThen we are told that an infant has had a slight fever 



Hodenpyl in the American Journal of lledleal Science. March I 



THE SIGNIFICANCE OF TONSILLITIS IN » HILDREN 



;.;i 



that passed off very quickly and has beeD attributed to "teething," tonsil- 
litis among other diseases should be suspected. 

The onsei is sudden. Fever is high. The temperature reaches 102 
and may rise to 1 n r> ° \-\ Vomiting frequently occurs. On the tonsils we 
find intense redness, and the lacunae are covered with whitish or yellowish- 
white spots, which rarely coalesce but appear as yellowish dots. 

Treatment. — Immediate relief to an inflamed tonsil can be given by a 
spray of 1 to 10,000 adrenalin chloride. Externally a hot flaxseed poultice, 
or in some eases with fever an ice collar, will render good service. 

Internally 1-drop doses of tincture of aconite, repeated every hour for 
live or six doses, will reduce fever, promote diaphoresis, and frequently abort 
the condition. A dose of calomel. y 2 grain, repeated every two or three 
hours until liquid stools are produced, is valuable. A steam atomizer con- 
taining a spray of beechwood creosote or pine-needle oil. to be used every 
two or three hours, loosens viscid secretions. 

Food. — As there usually is pain on swallowing solid food, it is better 
to give small quantities of liquid food. Ice-cold chicken or calfsfoot jelly, 
ice cream, raw scraped pulp of meat, the yolk of raw eggs well beaten with 
sugar, buttermilk or zoolak, is nutritious and grateful to an inflamed throat. 

The Significance of Tonsillitis ix Children. 

A diagnosis of tonsillitis or quinsy is usually thought to imply that we 
are dealing with a benign, easy-going condition. That the reverse is true 
is very apparent when a critical inquiry will follow the termination of each 
and every case. In a series of 12 cases of follicular tonsillitis taken at 
random as I saw them, the bacteriological diagnosis in T of these eases was 
diphtheria. 

The frequency with which endocarditis and nephritis are seen implies 
that there may have been some antecedent disease from which pathogenic 
bacteria caused the valvular heart lesion, or possibly a nephritis. 



Follicular Toxsillitis. or Follicular Catarrh. 

Follicular catarrh is the most frequent form of inflammation of the 
tonsils. 

Bacteriology. — The examination of the purulent plugs of follicular 
angina reveals : — 

fa) Staphylococcus. 

( h i Streptococcus. 
(c) Pneumococcus. 



432 DISEASES OF THE NOSE AXD THROAT. 

Staphylococcus angina is a relatively harmless inflammatory lesion 
passing off without complications. 

The streptococcus variety is a severer type of disease associated with 
fever and glandular enlargement. This disease is associated frequently with 
a general toxaemia and may be followed by nephritis or septicaemia. 

The pneumococcus form is usually ushered in with a chill and some- 
times runs a course similar to that of pneumonia. There is usually a red- 
ness and swelling of the tonsils, lacunar catarrh, and increased secretion, 
which agglutinates and shows itself at the follicular openings as yellowish- 
white spots. 

The lymphatic glands at the angle of the jaw are sometimes enlarged 
and tender on palpation. 

Croupous Toxsillitis. 

This is a severer form of inflammation than the one above described. 
It involves the whole structure of the tonsil and most especially the crypts. 
The large quantity of fibrin which is poured out forms a distinct pseudo- 
membrane. It is very difficult to differentiate this from diphtheria. A 
culture should be taken in all cases (see the "Diagnosis of Diphtheria"). 

We cannot differentiate this disease from true diphtheria clinically 
except by resorting to bacteriological cultures. 



Ulcero-mevlbraxous Toxsillitis. 

This disease was first described by Vincent 1 who maintained that it 
was caused by a fusiform bacillus, although a spirillum was found asso- 
ciated with it. 

Microscopically, there is a spindle-shaped bacillus along with spirilli. 
The bacillus does not stain with Gram. A clear culture is hard to obtain. 

The pseudo-membranes, whitish or grayish -in color, are easily detach- 
able until the third day, when the ulcer forms. This ulcer corresponds 
to the portion of the tonsil occupied by the pseudo-membrane. Around its 
edges the mucous membrane is reddened. The accompanying symptoms are 
difficulty in swallowing, fever, anorexia, headache, and swelling of the 
submaxillary glands. The pseudo-membrane does not increase when this 
piece of membrane is detached. The ulcer heals. 

It resembles croupous tonsillitis in its general appearance. It is often 
unilateral. The yellowish exudation seen on the tonsil greatly resembles 
diphtheria. It is a superficial necrosis, and when this tissue is wiped 
away with a swab bleeding occurs. 

There are swollen lymph nodes at the angle of the jaw. 



1 Arch. International de Larvnsrolo^ie, 189S, No. 1. 



•HLEGMONOI s TOXSILLH [S. 



i.;:; 



This disease is a local process and rarely lias constitutional symptoms 
accompany ing it. 

Prognosis. — The prognosis is excellent. 

Treatment. — Gargle with bichloride, 1 to 2000, or with a weak solution 
of permanganate. 

Locally, iodine, or 3 per cent, peroxide of hydrogen or 10 per cent, 
nitrate of silver solution, can be repeated in twelve hours if no improvement 
is noted. 

A B 




Fig. 127. — Vincent's Bacillus Found in Ulcerative Angina. A. Fusi- 
form bacillus having a thickened center and tapering toward both end-. 
Also spindle-shaped bacilli. B. Fusiform bacillus having spores. (Original.) 

Phlegmonous Tonsillitis (Quinsy: Peritonsillar Abscess). 

This form of angina is usually caused by an invasion of the staphy- 
lococcus. 

When the cellular tissue surrounding the tonsil is infected the inflam- 
mation may terminate in : — 

(a) Eesolution. 

(b) Abscess. 

It is one of the rarer forms of inflammatory conditions met with in 
children. • 

Symptoms.- — The symptoms are similar to those of follicular tonsillitis. 
The temperature rises to 101° and 10*2° F. Sometimes as high as 105° F. 

The child, if old enough, will complain of pain on swallowing, and 
at times it may be impossible to open the mouth. On examining the throat 
the inflammation can he seen. There is a marked congestion and oedema 
involving the tonsils, fauces, and uvula. 

Holt reports a case of torticollis several days before the diagnosis of 
quinsy was established. 



484 



DISEASES OF THE ROSE AND THROAT. 



Treatment. — Aconite in 1-drop doses, repeated every one or two hours 
for the first day. will frequently abort the disease. Guaiacol carbonate given 
in 1- to 5- -rain doses every three or four hour-, has served me very well in 
some instance - 

Local Treatment. — Local treatment consists in spraying the throat 
with a 1 to 2000 bichloride of mercury solution everv two hours. 

An ice-bag over the neck will sometimes relieve inflammation. The 
external application of leeches will relieve congestion. When fluctuation 




Fig. 12S. — Throat Spray. 

is felt the pus should be relieved by making a deep incision with a long, 
pointed bistoury. 

The Danger of Hemorrhage. — Laryngologists. as a rule, advise great 
caution in operating in this region owing to the large number of blood- 
ssels located there. 

After the incision is made the wound should be enlarged by inserting 




Fig. 129. — Throat Ice-bag. 



a polypus forceps or an artery clamp and separating the blades. By this 
means we can easily evacuate the pus and do not run the risk of bleeding. 

I am indebted to Dr. George F. Shrady for this valuable surgical hint. 



Cheoxic Hypertrophic Tonsillitis. 

The chronic enlargement of the tonsils is due to recurring inflammatory 
attacks. This hypertrophy comes from a proliferation of the lymphoid 
tissue and an increase in the connective tissue stroma. 

Etiology. — It is usuallv found in rachitic and subnormal children. 
Bad ventilation and improper hygiene are among the prime causes of this 



CHRONIC HYFERTROPH - 

- eral hundred children examined by me in one 
- for vai suffered with en! _ 

All of these children lived in tenement houses, and we d sso- 

eiate the crowded, ill-ventilated apartments with the poisoned air inspired 
and its - g throat 

Pre. - _ - rheumatism in the parent*, have heen 

author? as causative fact 
Symptoms. — When we are told that a:: infai - so i s and breathes 
•uth open, then enlarged tonsils may he suspected as the cause, 
her hand an inspection of the post-nasal spaces should also be made 
to eliminate the presence of adenoids as the probable cause of the difficult 
respiration. 

Deafness can rarely be attributed to enlarged tonsils. It is more often 
caused by the closure of the Eustachian tubes due to adenoids. The nasal 
tone of voice often accompanies enlarged tons 

Course. — Enlarged tonsils increase during childhood and remain per- 
manently until puberty arrives, when they usually shrink in size without 
treatment. 

The indications for ihe removal of chronic enlarged tonsils are : — 

1. Where there are repeated attacks of tonsill: - 

2. Where there is inability to breathe sufficiently through the nose, 
with snoring, during sleep. 

Nasal voice and deficient articulation. 

4. Deafness and attacks of earache. 

5. Tendency to pigeon-br 

When any or all of the above conditio:. - :hen a guarded opinion 

should lie given until i in whether or no the 'implicated by 

aden- 

In the latter cases the removal of the tonsils BSce to cure the 

patient until the rhino-pharynx is treated for the removal of the adenoids. 

There are few conditions met with in children which are more satis- 
factory from a therapeutic standpoint than the operation for tonsils and 
aden 

Dangers. — 7 -ire 1 collected . nsillotomies. In 9 cases bleeding 

took place. In none of thes - was it fatal, and in several it wa- 

seri- - 

Lefferts- lays stress on the ascending pharyngeal artery as being one 
of the most, if not the most, prolific source of severe bleeding after ton- 
sillotomy. It is important to inquire if children suffer irith haemophilia 
( bleeders ) ; in such cases fatal haemorrhage will frequently occur. I have 



Sajou-fs Annual. 1891, vol-, iv and r. 
Archives of laryngology, vol. iii. p. 43. 



ESEAS] 



IZI 1" -I .-.".'I 133 



et with a case of congenital - in which a serious haemorrhage 

followed a tonsillotomy. This was evidently due to a syphilitic- degeneration 
of the blood- - 

The Operation- — The bistoury is rarely or never used for this opera- 
tion. Some operators use a wire snare. In my experience the adjustment 
of a snare in an unruly ehild is so difficult and so much tin. is I -:. that 




I _ .30. — The Baginskr Tonsilloto 



not practical. My preference has been for some form of tonsillotome.- 
The Mackenzie type is a very good one. The Bagin- iJotome is one 

of the besr See Illustration F _ 1 1 1 is simply ; sharp-bladed guil- 

lotine and can be xer; 




Fig. 131. — The Mackenzie Tcmsillotome. 

# 

Haemorrhage following the operation need not cause anxiety. When, 
\r~~-r:. '---— .::'.. ;_r : - : ... ■-..."■.. . - - Tin in ~1I 

fjih m ) should be liberally used. It may be applied in the form 

~T»ray or by means of a cotton ple._ bed with the solution. The 

galTano-cautery or the local application of peroxide of hydrogen is fre- 
quently usefuL In older children small pieces of cracked ice or ice cream 
will control bleeding. 

The Use of an Anaesthetic. — The local application of a 10 per cent, 
cocaine solution, has been recommended bv a grreat manr authors. I have 



Bead chapter on "Anesthesia in Children," page 930. 



It BEK( I U >SIS OF THE TONSILS. 



137 



used cocaine in children and have Been very bad constitutional effects, such 
as severe cardiac depression, nausea, and frequently vomiting following its 

use. 

Spraying the tonsils with ethy] chloride for several seconds produces 
local anaesthesia. It is very valuable with sensitive children. In some 
instances a few whiffs of chloroform arc necessary to have the child com- 
pletely under control. 

Chloroform is very rapid, but it must be cautiously given. 

It is advisable to operate before feeding, so that in the event of vom- 
iting food should no1 be expelled. 

It is advisable to thoroughly swab the mouth, pharynx, and tonsils 
with an antiseptic solution before the operation. For this purpose use: — 

Listerine 1 part 

Sterile water 5 parts 

Or Dobell's solution. 

Apply with a cotton swab. 

Normally pathogenic bacteria abound in the mouth and post-nasal 
spaces. Alter a tonsillotomy a white croupous deposit resembling diph- 
theria will be seen. This should not be considered a diphtheritic infection 
unless the Klebs-Loeffler bacillus can be demonstrated. 

Owing to the raw surfaces following a tonsillotomy the greatest care 
must be used to isolate the patient from infectious diseases. Scarlet fever 
and diphtheria will gain access much easier soon after this operation is 
performed. 

Tuberculosis or the Toxsils. 

Schlesinger states {Forts, cler M eel. Pediatrics) that "up to the present 
time the parallelism between advanced tuberculosis of the lungs and tuber- 
culosis of the tonsils, as also that between mild or passed tuberculous 
processes of the lungs, with the escape of the tonsils, has only been demon- 
strated in the case of adults, but has not been observed in children. He was 
able to confirm this parallelism also in children, having found 12 cases of 
tuberculosis of the tonsils in 13 of florid tuberculosis of the lungs. The 
diagnosis of tonsillar tuberculosis is hardly possible microscopically, for the 
reason that tubercular ulcerations are only found very rarely on their 
surface; neither were the tonsils hypertrophied without exception, but 
were found pale and firm in nearly two-thirds of the cases. In 9 cases 
examined for the purpose, the tonsils were found to be affected bilaterally, 
although not with equal intensity. As to the relation between tuberculosis 
of the lymphatic glands of the neck and that of the tonsils, in !> cases the 
author found that the tonsils were healthy in 2. lie inclines, therefore, to 
the view that a primary tonsillar tuberculosis is not to be taken for granted 
in all cases; but we must take into account the possibility of their infection 



438 DISEASES OF THE NOSE AND THROAT. 

by cheesy cervical glands, by means of the return flow of lymph. The 
author finds some support for this view from the fact that in these cases 
the recent tubercles are. situated at the base of the tonsils away from the 
crypts." 

L. Kingsford 1 examined the tonsils removed post-mortem from 17 
children, varying in age from 1 months to 9 years. All showed cervical 
glandular enlargement, and in 11 it was obviously tuberculous. Of the 
17, tonsillar deposits were found in 7, but only 3 exhibited any naked-eye 
tuberculous changes. Of these 3, 1 showed ulceration, a second scarring, and 
a third a sebaceous focus. Practically all the IT were cases of secondary 
infection from either blood or sputum. The parts of the tonsils which 
were the seats of the lesions were usually the lymphoid follicles not far 
from the epithelial surface, but it is not possible to trace bacilli in from 
the crypts -or surface of the organs. The author believes it possible that 
infection may work through healthy tonsils to the cervical glands, the 
former becoming infected at a later period. 

Tuberculous tonsillitis is a very rare affection. The tonsils are rarely 
if ever the site of primary inoculation in pulmonary tuberculosis. 

Adexoid Yegetatioxs. 2 

Adenoid vegetations consist of a hypertrophy of the adenoid tissue 
which exists normally in the naso-pharynx. 

Pathology. — In a less severe form the growth may be confined to the 
roof of the naso-pharyngeal cavity. In severe forms the vegetations are 
very numerous, irregular in shape, and extend from the roof of the cavity 
to the lateral walls. They grow from the fossa of Eosenmuller. They 
frequently cover the orifices of the Eustachian tubes. There are fre- 
quently, according to Hall, between the enlarged pharjmgeal and faucial 
tonsils, and sometimes the adenoid tissue at the base of the tongue, the 
so-called lingual tonsil. 

The difference between vegetations and an enlarged tonsil is that the 
tonsil has a great amount of connective tissue due to the irritation produced 
by the passage of food, whereas the vegetations by their situation are pro- 
tected from these injurious influences. 

Symptoms. — The "adenoid habitus," the pinched expression of the 
nose and the long drawn face, are very typical. There is frequently lateral 
narrowing of the alveolar arch and prominence of the upper incisor teeth. 
Owing to the interference of respiration the mouth is kept open. The lips 
are swollen and thick. 



ir The Lancet January 9, 1904. 

2 For "Congenital Adenoids/' see clinical history on page 55. 



PLATE XIL 




Chronic Enlarged Tonsils and Associated Congested Throat, very frequently 

seen. ( Original. ) 




A case of Granular Pharyngitis. Large masses c<~>ald be palpated in the 
rhino-pharyux. ^Orig::.. 



ADENOID \ l.'.KTA rioxs. 










- 'rooted attention 1 to the distention of the transw - 
veins as one of the indications of tin 

ss. — Deafnese - eqnently cansed by the pres adenoids. 

The amount «»t' interference - d by the adenoids will depend <»n the 

relation of the Eustachian tube orifice to the vault of the pharynx. ]f the 
orifice be situated high up. a small amount of growth will occlude it and 
cause auditory trouble. When the orifice is situated low down there may 
be extensive vegetations without the Eustachian tube being implicated. 2 
The voice has a muffled 
- id with a nasal twang. 
The letters m, n, and ng 
cannot be pronounced. 
Stuttering or stammering 
can frequently be cured if 

_ rions are removed: 
the explanation being that 
the spasmodic actions of the 
muscles of the throat are 
due to reflex irritation. 
Earache frequently accom- 
panies adenoids. 

Bed wetting is usually as- 
sociated with adenoids. 
Among several hundred 
children examined in the 
children's service of a large 
dispensary, it was rare to 
find a case of enuresis that 
was not associated with 
adenoid vegetation. 

Diagnosis. — The mouth breathing, the snoring at night, the adenoid 
face, are in themselves sufficient to establish a diagnosis. To examine the 
rhino- pharynx for the presence of adenoids, have the nurse seated with the 
child on her lap, firmly pinning the child's feet between her knees. While 
the right, hand confines the child's arms, the left hand is used to support 
the head. The physician should then separate the jaws with the aid of a 
mouth gag and explore the post-nasal space with his index finger. In the 
absence of a gag a clean cork or the handle of a spoon protected by gauze 
can he ue - ;>arate the jaws. 

If the child is very unruly it is wiser to pin a sheet securely across 
the arms and examine in the dorsal position. 



* 





Fig. 132. — Typical Adenoid Face in a Cretin. 
(Original.) 



1 British Medical .Journal. 1887, p. 459. 
1 Sajous*s Annual. 1SSS.. vol. iii. p. 278. 



-:-:. 



DIS 






The physician can best make the examination by standing dirt : 

: - "•••" ' :_ir :777 

In :... . _ — : ".■:„: 7 _:_:_:_>- . n*is: : . 

~: .1 _'.t :: :::t^: ■.._ _ 7:- ::_:, ilir-' :■: H".v. — •.: :^~:7" .-i: l::-v : .: t_i 

'.-.:::..:-. E.~r"r: .... ' : -.- : i .- i_.".::_ :..: -.. . 

r^:7;.77 TIit-t :..:. ~ ... :- : — 



: - - 
; nstitntionaL as: — 

L"~_"_ _: : >'_..:. 
7\; '. -. ."7 «> 
7::.:. -:_:a. 
3. Other conditions, such as : — 

A " : I 

I : . : ---_ _• t 7 ab- 




) 



I :-r;7 m; .-- :: 7res- 

tion. 
I ::.-:- : - :: -.\'.r~ 

or pharynx. 
7r.77:-7::^. 7-~t::.-.-7 
~ ." - : * 

These hare to be carefully considered. These conditions may earisi 
with adenoids, bnt when alone may cause symptoms jsrmilar to those occa- 
sioned by the presence of the hypertrophied tissue, so an operation may 
not result in the promised cure. In infants the gramhrmg finger, on 
" . : ' '-" : :~: 7z .-. > "v: : : ~.. :- v--~: ::. .in \ 7.r :..:_ :s>:~7; ~:tt : : .i~~ :~ 
t r~-y.-^l 7: t 7 ~ 7.:-.- ;~T.;iiz. 'l-. .::.--.-.- n~?: r>:77:7i 7i: 7i_> 
n-:si? 

Pr:r:::s:5 — 7':.- 7- :7> ::-.::_• :::::. :7i - :- — ::.t :: ; 7~ ::7 i:r : 
Repeated attacks of coryza, chronic rhinitis, arrest of nasal development, 
nasal stenosis, and month breathing, with the associated mental listlessness. 
There is a tendency to bronchitis, to spasmodic cronp and asthma. Children 
with adenoids nsnally hare very poor appetites. There is an associated 



= : ::-_ — : : il -.:....:..: 



- " ; . - 



ADENOID v; 44 1 

catarrh. Some author* 1 state that measles, Bcarlet fever, ami ear 
troubles are more frequently found in children where adenoid- Their 

- nee is therefore a menace and they certainly invite infection. 

Treatment.— . 1 Copenhagen, certainly deserves the credit for 

the plan of treatment used in these a The following method has been 
used by me f«»r some time : — 

It is best to use an aiutsthetic. 1 si children with adenoids are of a 
neurotic temperament. 

A rapid anaesthetic in children is chloroform. Some authors a* 
the use of nitrous oxide followed by ether as the best means of producing 
anaesthesia. Deep anaesthesia is uncalled for, as in that condition the • 
reflex would be abolished. It is better to do the operation completely rather 
than put a child to the pain and discomfort of repeated sittings. Two or 
more sittings may be necessary if the child is not anaesthetized. The evening 
before the operation a 1-grain dose of calomel or a wineglass of citrate of 
magnesia has a beneficial effect on the bowels, The position of the child 
during the operation is of great importance. Some operators prefer the 
head over the end of the table. Butlin- says the patient should lie on the 
side with the thighs flexed, the head a little forward on a low pillow. 

The Operation. — The Gottstein curette or its modification is best 
adapted to work in the antero-posterior diameter of the naso-pharynx. The 
Lowenberg forceps or its modification is used to grasp the mass and is 
preferred by many operators. 

With the curette the portion removed is apt to be lost and might even 
drop into the larynx, although it is the safest instrument to use with very 
young children. The best type of forceps is the Graedle or its modification 
by Concannon. This forceps has an extensive cutting edge, hence tearing 
is unnecessary. 

Operating Without an Antithetic. — The child should be placed in an 
upright position and held by an assistant. A mouth gag is used, and the 
closed forceps is introduced. The forceps is then opened widely and 
pressed well upward and behind. The mass is seized and the forceps with- 
drawn. "The finger should always be introdneed-to be sure of the location 
and extent of any remaining masses. The latter can be removed with the 
finger, curette, or with smaller forceps. 

If the Gottstein curette is used it should be carried well up into the 
vault, carrying the soft palate forward: then it should be brought down 
with a bold sweep, to the vault of the pharynx. The steel nail is frequently 
advised by some operators as a means of removing adenoids. In spite of the 
most careful treatment 5 adenoids will frequently recur. 



1 Centralblatt. toI. i " ; 

- Lancet, vol. i. 1893, p. 363. 

, W. K. Simpson February 13, 1902. 



442 DISEASES OF THE NOSE AND THROAT. 

Hcemorrhages After Operation. — The local application of diluted 
peroxide of hydrogen, or Monsell's solution undiluted, is sufficient to control 
any ordinary haemorrhage. If, however, it is a case of haemophilia or pro- 
fuse bleeding, then the subcutaneous injection of 30 cubic centimeters 
sterile horse serum into the thigh or abdomen will control the bleeding. 

The After-treatment. — The after-treatment will consist in giving syrup 
of hypophosphites, y 2 drachm, two or three times a day, or the tincture of 
iron, given in 5- to 20- drop doses three times a day, will have a good local 
and constitutional effect. 

The application of a diluted solution of iodine is frequently useful : — 

IJ Iodine . . . .' 2 grains 

Potass, iodide 10 grains 

Glycerine 1 ounce 

M. Sig. : To be applied with a cotton swab every two or three hours. 

Codliver-oil and malt extract are among the restoratives indicated for 
the after-treatment. The most important part of the after-treatment con- 
sists in the strict application of hygienic measures. The child should be 
placed in a room in which there is fresh air, windows open night and day. 
If a child is old enough we should teach it how to breathe. Out-of-door 
exercise should be insisted upon. Deep inspiration and expiration, and 
pulmonary gymnastics are just as important as attention to the food. Milk, 
meat, eggs, cereals, and fruits should be ordered, depending on the age and 
requirements of the case. 



Pharyngitis. 

The proximity of the pharynx to the tonsils renders this portion of 
the body very prone to harbor pathogenic bacteria. Infections therefore 
spread from the tonsils to the pharynx or from the uvula to the pharynx. 
In the article on tonsillitis I refer to this region as an avenue for infection 
through which tubercle bacilli may enter the lymph channels and set up a 
posterior basic meningitis. The diplococcus intracellularis can also enter 
the pharynx and by this channel set up a cerebrospinal meningitis. The 
pharynx is therefore an important part of the body to be inspected when 
obscure febrile conditions exist. 

Treatment. — Local applications of dilute Lugol's solution applied to 
the retropharynx once only by means of a cotton swab, and a spray of 
DobelPs solution after feeding and at night before retiring is a good means 
of destroying pathogenic bacteria in influenza or in catarrhal infections. 
During an epidemic it is good to employ the Dobell spray as a prophylactic. 



RETROPHAItt NGEAL ABSCESS. I |:; 

Retroph lryngeal Abscess ( Retropharyngeal Lymph Adenitis). 

This condition may be clue to mechanical irritation or to direcl infec- 
tion. The most common forms met with in children arc evidently due to: — 

1. Local infection. 

2. Abscess caused by a tubercular in (Vet ion or where caries of the 
cervical vertebrae exists. This latter condition we meet in older children. 
It is usually a sequel to the specific infections, and may follow scarlel fever, 
measles, or diphtheria. It is most frequently associated with influenza and 
tuberculosis. Rachitic and syphilitic children are predisposed to this dis- 
ease. Catarrhal affections of the upper air passages also invite this disease. 

Pathology. — The retropharyngeal Lymph nodes are described (Simon) 
as forming a chain on each side of the median line between the pharyngeal 
and prevertebral muscles; these undergo atrophy after the third year. 
Sometimes adenoids will cause a swelling of the glands, giving rise to fever, 
but they will not suppurate. At other times the swelling of the retro- 
pharyngeal lymph nodes will be associated with external cervical adenitis. 
It is important to recognize 'this condition owing to the serious nature of 
the disease. 

Symptoms. — This affection usually develops very suddenly; the infant 
will refuse the breast or have trouble in swallowing. The food is most 
commonly regurgitated through the nose. Such infants will have labored 
mouth breathing. The head is thrown back, there is severe dyspnoea, occa- 
sionally asphyxia — laryngeal stenosis due to pressure of the abscess on the 
larynx, interfering with respiration. There is a peculiar snoring sound. 
With the index finger in the throat the soft fluctuating tumor can be felt. 
On examining the throat with a good light the bulging of the pharyngeal 
wall will be noticed. 

The temperature will range from 102° to 103° F., sometimes higher. 

Diagnosis. — The diagnosis should be made with the finger, by a careful 
palpation of the post-nasal and pharyngeal spaces. Mouth breathing due 
to adenoids will not cause sudden symptoms of suffocation. The sudden- 
aess of interference with respiration points to the development of an abscess. 
The following cases will illustrate this condition : — 

Case I. — An infant about fifteen months old was brought to my office by Dr. J. 
Martinson. The history was loss of appetite, regurgitating of food through the nos- 
trils, mouth breathing, and bulging of the pharyngeal wall. Temperature, 101° F. 
Cervical glands enlarged. The diagnosis of retropharyngeal abscess was made. An 
incision made in the abscess liberated the pus. The abscess cavity was cleansed 
With a 1 to 2000 bichloride solution. The child recovered. 

CASE II. — A musing infant, less than 1 year old, seen with Dr. J. Brandeis, suf- 
fered with retropharyngeal abscess. The treatment consisted in hot fomentations. 
When fluctuation was detected, an incision was made with a curved bistoury; the 
lower half of the blade was protected with cotton. After the incision the wound 



444 



DISEASES OF THE NOSE AND THROAT. 



was enlarged by introducing and separating the blades of a polypus forceps. The 
child recovered. 



mc.'o*. 


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Fig. 134. — Temperature Chart from a Case of Retropharyngeal Abscess. 

(Original.) 

Treatment. — Some children require local applications. Antiphlogis- 
tine is a convenient local application until suppuration is established. Flax- 
seed poultices are sometimes well borne. 

No time should be lost if pus is present. The abscess cavity should 
be opened and the pus liberated. To prevent the pus flowing into the 
trachea, it is best to keep the head well forward. ' The use of a gag is not 
necessary if the tongue is depressed and the incision made with a small- 
bladed knife similar to a tenotome. After the pus is evacuated the parts 
should be cleansed with a 1 per cent, carbolic solution or a 1 tp 2000 
bichloride solution, and the wound treated on general aseptic principles. 
Restorative treatment will consist in giving codliver-pil, liypophosphites, 
and last, but not least, food and fresh air. ■ *— ^ 



Spasmodic Laryngitis (Catarrhal 'Croup: Spasmodic Croup). 

This form of acute catarrhal spasm was first' described by Goodhart. 
The disease is simply an acute catarrhal inflammation associated with a 
severe spasm of the larynx. Infants under six months of age are rarely 
affected, and until 5 years the disease is most common. It occurs as fre- 
quently in well-nourished as in frail rachitic children. 

Catarrhal or spasmodic croup is frequently the result of hypersecretion 
in the naso-pharynx. When croup appears suddenly it should not be feared. 
especially so if the child was well during the day. It simply results from 
post-nasal secretions accumulating while the child lies on its back. Such 



SPASMODK LARYNGITIS. 



I I.', 



croup. his attacks will always yield to a good emetic dose of syrup of ipecac. 
Such children while awake Buffer from the irritation of the secretion and 
swallow the same by day. A point to remember in this connection is that 
croup which is fatal or serious comes on very slowly and cannot be per- 
manently benefited by giving an emetic 

Symptoms. — The symptoms are similar to those of laryngeal diph- 
theria. It is at times very difficult to differentiate catarrhal spasm of the 
larynx from diphtheritic croup. It is frequently found in infants with 
adenoid vegetations and post-nasal catarrh. An inflamed uvula, diseased 
tonsils, and pharyngeal catarrh are among the contributing factors. The 
mucous membrane is red and swollen. At first it is dry, but afterward it is 
covered with a watery mucous secretion. The catarrh may begin in the 
subglottic portion of the larynx and may he attended by some mucous, 




Fig. 135. — Oil Atomizer. 



oedema. It usually follows catarrh of the nose and pharynx, or it may 
be an extension of the disease from the bronchi. 

Children suffering from this form of croup will usually have repeated 
attacks of the same. The slightest exposure to cold and irritation by dust 
are among the exciting causes. 

After an attack of rhinitis lasting one or more days, the child will 
suddenly awaken at night with a hoarse, barking cough and the face will 
be extremely congested. The attack terminates by a long, noisy, high- 
pitched inspiration. 

On inspiration we note deep recession of the suprasternal fossa, the 
supraclavicular spaces, and the epigastrium. There is also depression of 
the intercostal spaces and the walls of the chest, The pulse-rate will be 
greatly accelerated. The temperature rarely rises over 102° P., although 
in some instance- it may reach 103° F. Owing to the dyspnoea, children 
will usually gasp and try to sit up. The forehead and sometimes the 



446 



DISEASES OF THE NOSE AND THROAT. 



whole body will be covered with large beads of perspiration after an attack 
of laryngeal spasm. 

Prognosis. — This is invariably good. A point to remember is that 
when croup appears suddenly, it is of a mild type resulting from catarrhal 
trouble. The dangerous form of croup comes on very slowly, and in this 
type we must always look for diphtheria as a causative factor. 

Treatment. — In the treatment of diseases affecting the air passages we 
aim, roughly speaking, at two things : — 

First. — To relieve the cough. 
I. — To cure the dise 




Fig. loti. — Steam Atomizer. 

Directions for Using a Steam Atomizer. — Put the liquid to be atomized 
in the cup D. Fill the boiler F about one-half full of water. Fill the 
lamp I with alcohol (use nothing but alcohol in the lamp), and after 
lighting it place it under the boiler. As soon as the water boils the medi- 
cated steam will be thrown out through the tube E, and can be inhaled 
through the shield A. 

Locat Treat:>:e^t. 

R Menthol 5 parts 

Alboline 100 parts 

Or: — 

R Menthol 5 parts 

Paroleine 100 part- 
Either of the above solutions can be used in the form of a spray every 
two or three hours. This lubrication soothes the mucous membrane. 
GuaiaeoL, 2 per cent, solution, dissolved in alboline. can also be used. 



s - ins. 

R Balsam ol ' . drachm 

• '-hm 

1L Sig in 2 drachma of alcohol, mill into a pint of 

boil in _ 1 in the ionn of a spray, by nn . atomizer. 

Fig. : 

When a tubercular condition is sua sote may l>e added to the 

- ray with marked benefit. 

Intralaryngeal inj - in the treatment of dis - in the bronchi 

and larynx have been used many years. 

L852 nipson described a glass and silver syringe for 

this purpose. The injection was made through the glottis into the cavity 
of the larynx and not injected under the mucous membrane. This injected 
fluid pase - :iie larynx and *nd readily enters the larger 

bronchi. 

Local applications of iodine and glycerine are frequently valuabl- : — 

R Iodine . . . 3 grains 

Glycerine : 

Kali iodid . . -> grains 

AL Sig.: Apply with a cotton swab, on larynx. Once daily. 

When this catarrh persists, single application of the following will 
frequently abort an acute attack — 

R Argenti nitriei . . 10 grains 

Aquae destilla: e 1 ounce 

AL Sig. : Apply cautiously over the larynx. 

— The most rapid method of relieving catarrhal accumulations 
is in giving an emetic. The choice of the same depends on individual 
experiem :e and harmless emetic, quite rapid in action, is a tea- 

spoonful of syrup of ipecac. The same dose may be repeated in half an 
hour if not effectual. 8] ~ iilae comp.. commonly known - 's hive 

syrup, in teaspoonful doses, is also a mild drug, producing emesis. Musi 
water and sulphate of zinc are also useful. Tartar emetic in 1 / 1# -grain 

s, gradually increased, is valuable. My favorite emetic is sulphate of 
copper. 1-grain doses, with % ounce or less of water. This usually produces 
an instantaneous effect. 

When children are obstinate and will not swallow, a l / M -grsdn or - 
grain tablet of aponiorphia. given hypodermic-ally, may be repeated in ten 
or fifteen minutes if necessary. This is a convenient and rapid means of 
producing emesis. Emesis should not be repeated oftener than once in 
twenty-four hours, and then always with due regard to the condition of a 
child. 



448 



DISEASES OF THE NOSE AND THROAT. 



Inhalations of steam impregnated with turpentine or pine-needle oil 
have served me very well. For producing this steam a croup kettle or 

a steam atomizer may be used. 

The steam loosens the viscid 
secretion and can be used every hour 
or less often, depending on the 
urgency of the case. 

Foreign Bodies in the Larynx. 

Foreign bodies such as fish- 
bones or particles of food are occa- 
sionally aspirated into the larynx, 
causing coughing and irritation. In 
some cases laryngeal stenosis and 
symptoms of asphyxia result. No 
time should be lost in commencing 
treatment, owing to the danger of 
suffocation. 

The hypodermic injection of 
apomorphia ( 1 / 50 grain) until emesis 
is produced, or syrup of ipecac, 
several teaspoonfuls given by mouth, 
will occasionally dislodge the foreign 
body. If this is not successful a laryngologist should be sent for. A 
physician who is inexperienced with the larynx should refrain from pro- 
longed attempts to dislodge the foreign body, as in most cases only harm 
can result therefrom. If asphyxia threatens, tracheotomy should be per- 
formed. Those experienced with intubation should first try the effects of 
the large caliber tube known as the foreign-body tube (see chapter on 
a Intubation ,? ). 

Coughs of Reflex Origin. 
Night Cough. 

A very troublesome form of cough is frequently heard at night. The 
history given is that the child is quite well during the day, but has a dis- 
tressing cough at night. 

The position of the child on its back permits naso-pharyngeal accu- 
mulations to stagnate; hence, this cough occurs when the child is on its 
back. Very young children do not expectorate, nor can they clean the 
nose. 

Diagnosis. — A history of cough at night only points to naso-pharyn- 
geal disease. As a rule adenoids and chronic tonsillitis or pharyngitis 




Fig. 137.— Croup Kettle. 



i 01 ghs. 449 

should be suspected. The absence o\' lexer and the freedom from < 
during the day indicate a local catarrh which gravitates when the child 
Is on its back. 

Treatment. — If adenoids are present they should be removed. Naso- 
pharyngeal catarrh should be treated by local applications of ' - per cent, of 
iodine and glycerine solution. The oaso-pharynx should be washed by 
means o\' a douche every morning and evening. A weak solution of 
boracic acid or bicarbonate of soda is very serviceable. In persistent 
catarrh codliver-oil should he given. 

Spasmodic Cough (Pseudo-pertussis). 

I have previously described a cough which occurs in children having 
catarrh of the upper air passages; sometimes this night cough is paroxysmal 
in character and the spasm resembles whooping-cough. 

Cause.- — The accumulation of the mucus in the region of the arytenoids 
and the vocal cords sets up a spasm of the glottis, resulting in attacks of 
suffocation. 

Symptoms. — A hoarse or barking cough, appearing in spasms with an 
interval of rest, is usually heard. The cough is frequently followed by vom- 
iting. The temperature is rarely above normal. 

Diagnosis. — The absence of the cough by day and the appearance of 
the cough in spasms when the infant is placed on its back always point 
to a local throat condition of a non-inflammatory character. 

Treatment. — Eemove the cause if any is apparent. Locally, astrin- 
gents are indicated. Kestorative treatment, consisting of iron and Fowler's 
solution, will sometimes permanently benefit the child. 

Useless Cough. 

Thompson and MacCoy, of Philadelphia; Francis Warner, of London, 
and Emil Mayer, of Xew York, describe an irritating hacking cough in 
children. Such children do not suffer with fever, but have a poor appetite, 
are thin and irritable. Warner studied a series of 22,000 children in 
schools, and he attributes this condition not to peripheral irritation, in- 
testinal worms, nor to any disease of the tonsils or pharynx, but to un- 
balanced central nerve action. 

Eeflex Cough. 

In post-nasal catarrh we frequently have a profuse discharge which, 
by irritating the pharynx, causes a cough. This cough frequently resembles 
that of an acute bronchitis. The examination of the lungs in such cases 
is usually negative. It is therefore advisable to examine the nose and 
throat in every case of cough. 



CHAPTER II. 

DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

The Lungs. 1 

The lungs in children occupy the same position as in adult life. The 
trachea of the young child is larger in comparison than in the adult; so 
also the bronchi are larger than in the adult. They occupy more space and 
are more numerous than in the adult, but the air-cells are much smaller. 
I have described in detail the method of examination of the thorax in the 
article on "The Respiration in the New-born Baby." 

The Diaphragm. 

The diaphragm occupies a higher position in children than in adults. 
Dwight studied a series of frozen sections and found the diaphragm in the 
infant corresponding to the eighth and ninth dorsal vertebrge. 

Points to be Noted in the Diagnosis of Diseases of the Lungs. 

auscultation. 

Acute catarrhal bronchitis: Sibilant and sonorous rales. Large and 
small bubbling rales. 

Capillary bronchitis: Sibilant, subcrepitant rales. 

Asthma: Sibilant, wheezing, sonorous breathing. 

Emphysema: Respirations diminished, absent, or prolonged. Low- 
pitched expiration. 

(Edema: Bilateral, subcrepitant rales. 

Pneumonia: (1) Crepitant rales; (2) bronchial breathing and bron- 
chophony; (3) broncho-vesicular breathing, crepitant, subcrepitant, and 
bubbling rales. 

Pleurisy: Friction sound with each respiratory act, best heard with 
inspiration. If the child controls the movements of the lung and keeps 
the pleural surfaces apart, then no friction sound is heard. 

Subacute pleurisy: Friction, absence of vesicular murmur, and vocal 
resonance. 

Fluid and air in pleural sac: Respiratory murmur absent, amphoric 
breathing above, all sound absent below, splashing rales. 



1 Acute tuberculosis, tubercular pneumonia, and lobar pneumonia are described 
in Part VII, in the "Acute Infectious Diseases." 

(450) 



VOCAL RESONANCE. 451 

Tuberculosis: Long, high-pitched expiration, breathing feeble, vocal 
resonance increased, adventitious rales, later bronchial breathing, bron- 
chophony. 

Tuberculosis, second stage: Cavernous breathing, amphoric breathing, 
gurgles, metallic echo. 

PERCUSSION RESONANCE. 

Vesicular: Uncomplicated lung. 

Dullness: Lung with increased proportion of solids. 

Flatness: Solids, fluids. 

Tympanitic: Large body of air. 

Vesiculotympanitic: Lung with increased proportion of air. 

Amphoric: Empty cavity with tense walls. 

Cracked-pot: Cavity with flaccid walls. 

RHYTHM. 

Normal rhythm: Kegular succession of the respiratory acts. 
Interrupted rhythm: Slight deposit in lung. 
Divided rhythm: Want of elasticity in lung. 
Prolonged expiration: Want of elasticity in lung. 

BREATHING. 

Vesicular: Uncomplicated lung. < 

Bronchial: Consolidated lung; compressed lung. 

Broncho-vesicular : Moderate consolidation, moderate compression. 

Cavernous: Flaccid cavity-walls. 

Amphoric: Tense cavity-walls. 

Exaggerated: Vicarious respiration. 

Diminished: Plastic exudation, want of elasticity. 

Absent: Fluid, air. 

VOCAL RESONANCE. 

Normal: Voice through normal chest. 
Bronchophony : Voice through consolidation. 
Amphoric: Voice in a cavity. 
2E go phony: Voice in compressed lung. 
Pectoriloquy: Articulate voice in cavity; in consolidation. 
Whispering pectoriloquy : Whispered articulation in cavity; in con- 
solidation. 

Cavernous whisper: Ill-defined articulation in cavity. 



452 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



Bronchitis (Bronchial Catarrh, Acute Bronchitis). 

Bronchitis, commonly known as bronchial catarrh, is one of the most 
frequent diseases of infancy and childhood. It frequently follows nasal 
catarrh, pharyngeal catarrh, or catarrh extending from the trachea. 

Etiology. — There are certain predisposing factors which favor the 
development of this disease. Children with deficient nutrition, suffering 
with anaemia, and those with a weakened framework having rickets, are 
more susceptible to this disease. Children affected with catarrh of the 
upper air passages frequently invite an extension of this inflammatory 
process. 

Bacteriology. — The pathogenic bacteria found in the bronchi are sta- 
phylococci, streptococci, colon bacilli, and diphtheria bacilli. The bacteria 
most frequently seen are the diplococci of pneumonia and streptococci; in 
addition to these the bacillus of influenza frequently gives rise to bron- 
chitis. Other germs found were bacillus pyocyaneus and encapsulated ba- 
cilli. Ritchie 1 states that the above micro-organisms were rarely found 
alone, but always associated. He does not believe that a definite germ is the 
causative agent. These same micro-organisms under different conditions 
frequently enter the alveoli and produce pneumonia. 

Pathology. — The anatomical changes noted in bronchitis are the same, 
irrespective of the cause. The disease may be limited to the large bronchial 
tubes or may extend into the finest ramifications. This tendency to extend 
into the capillaries is greater in children and still more so in infants. The 
accumulation of the catarrhal products in the smaller tubes adds a gravity 
of its own to the situation. It is well to emphasize this peculiar tendency 
of the trouble in those of tender age. 2 

On making a cross-section of the lung a muco-purulent discharge oozes 
from the bronchi. The same thick purulent matter can be forced out of 
the smaller tubes when compressing the lung between the fingers. The 
microscopic examination shows intense congestion of the superficial blood- 
vessels. Frequently there is a serous infiltration of the bronchial mucous 
membrane. 

When the infection extends into the smallest bronchi it is called "capil- 
lary bronchitis/'' Williams calls it "suffocative," owing to the severe symp- 
toms which develop. 

Capillary bronchitis is always accompanied by some alveolar catarrh 
and frequently passes on to a distinct broncho-pneumonia. Infectious secre- 
tions in the larger bronchi are sometimes sucked into the smaller bronchi 



1 Journal of Pathology and Bacteriology, 1900, vii, 1-21. 

Christopher: Article on "Bronchitis," "American Text-Book on Diseases of 
Children." 



BRONCHITia 453 

and frequently cause an inflammation of the lobule. A plug of mucus 
frequently acts as a valve in a bronchus, permitting some air to escape 
during expiration and preventing the entrance of air during inspiration. 

When all the air is expelled the lobule may collapse. This condition 
is known as atelectasis pulmonum. This condition is favored when the 
thorough expansion of the air tubes is interfered with. It is also favored 
by congestion, thickening of the mucous membrane, and the gummy secre- 
tions produced by bronchitis. 

It moreover accompanies those cases in which the position is not fre- 
quently changed. It is seen in rachitic deformities of the thorax. The 
most frequent place for this condition is at the border of the lungs. The 
collapsed area is of a dark red or purple color and shows a unifom red 
surface on section. It sinks in water, but can be insufflated unless inflam- 
mation has already begun (Williams). 

Eachford has shown that disease of the lymphatic system is a factor 
in producing malnutrition in children. In children having the latter con- 
dition we must not be surprised if we have a persistent bronchial catarrh 
baffling the ordinary method of treatment. 

Symptoms and Diagnosis. — The symptoms vary with the severity of the 
disease. In mild cases the temperature rises to about 101° F. at night: in 
severer cases the temperature will reach 102° F. and even 103° F. The 
respirations are quickened and labored and the pulse is accelerated. When 
the temperature is subnormal in rachitic children, then such low temperature 
should be looked upon as a grave symptom. On auscultation sibilant rales 
are heard anteriorly, but more prominent posteriorly. 

As the secretion from the mucous membrane begins the sibili gives 
place to loose mucous rales. Graves's point is worth noting, that "the 
more numerous the sounds heard at any one point to which the stethoscope 
is applied the smaller the bronchi involved." 

Much stress should not be laid on the sputum or the character of the 
expectoration. Children under 5 years rarely or never expectorate. The 
pulmonic resonance is usually normal. If the attack is a mild one, as the 
above-named symptoms would seem to indicate, then the symptoms will 
subside under palliative treatment. The greatest attention should be be- 
stowed on the pulse. 

A pulse-rate between 120 to 130 in a young child should be looked 
upon favorably. If the pulse is suddenly accelerated and reaches 1-iO 
to 160 and the respirations are increased to 60 or SO per minute, then a 
broncho-pneumonia should be suspected. Bear in mind that the normal 
ratio of respiration to pulse is about 1 to J+; when this is disturbed so that 
the ratio is 1 to 2, or even 1 to 3. we should suspect pneumonia. 

Prognosis. — This varies according to the severity of the symptoms and 
the condition of the infant before it was taken sick. Children having a 



454 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

cachectic condition or those having syphilis will certainly have a severer 
type of infection than children not so affected. In subnormal conditions 
bronchitis will frequently leave some traces, so that a "chronic bronchitis" 
is established. 

Treatment. — Hygienic Treatment: A child with bronchitis must be 
put to bed in a room having a temperature of 68° to 72° F. The air should 
be kept free from dust. The room must be properly ventilated. The pa- 
tient should be given as much sunshine as possible. Dark, ill-ventilated 
rooms will aggravate this condition. The body should be warmly clad — 
not too warm. Flannels should be worn next to the skin. A lukewarm 
sponge bath followed by friction with a coarse towel will stimulate the 
circulation and is very grateful to the child. If the child has a high tem- 
perature then a mustard foot bath should be ordered. 

Dietetic Treatment. — If the child takes a large amount of nourish- 
ment and assimilates the same, then the chances of restoring health are 
excellent. To rely on drugs and exclude food is to discard the most impor- 
tant part of the treatment. When the child refuses food by mouth, then 
rectal feeding should be resorted to, so that the body is sufficiently nourished. 
It is a good plan to predigest milk for feeble infants, hence peptonized 
milk or whey and soups and broths should not be forgotten. The yolk of 
an egg beaten up with sherry wine for a child several years old will be 
found a convenient method for giving nourishment with stimulation. Water 
is very important in the treatment of this disease, especially so when there 
is a large amount of expectoration. 

Medicinal Treatment. — If the temperature is over 102° F., 1-drop 
doses of tincture of aconite, given every two hours, will be useful to reduce 
the fever. All children who cough swallow their mucus, hence a laxative 
or an emetic will be very serviceable. A teaspoonful of castor-oil, repeated 
in six hours, is very valuable. As an emetic a teaspoonful of syrup of 
ipecac, repeated in fifteen or twenty minutes if necessary, can be tried. 
When rapid emesis is desired, 1 grain of sulphate of copper dissolved in a 
teaspoonful of water will be very effective. This dose should not be re- 
peated more than once in two or three hours. Apomorphin in doses of 
Vioo grain, hypodermically, is a very effective emetic. This is indicated 
when the child refuses to take medicine. 

When the secretion is very viscid then steam inhalations will be very 
serviceable. The steam atomizer will be found very valuable in young 
children who cannot be held over moist vapor. Steam impregnated with 
oeechwood creosote will be found not only a valuable means of loosening 
adherent mucus, but it has a decided therapeutic effect. It is a powerful 
antiseptic. 

Restorative Treatment. — Eestorative treatment, such as using an 
emulsion of codliver-oil or a malt extract, with or without iron, should not 
be omitted. 









BRON< lllAl. ASTHMA. 455 

Bronchial Asthma. (Hay Fever.) 

This is frequently called spasmodic asthma, owing to th< i spasmodic 
or paroxysmal dyspnoea associated with wheezing respiration. A pecul- 
iarity o( this condition is that children appear to be perfectly well during 
the intervals. 

Etiology. — Children having neurotic tendencies or those children of 
gouty families seem to be predisposed to this affection. Most writers on 
this subject believe that this condition is a vasomotor neurosis resulting from 
disturbed innervation of the pneumo-gastric or its ramifications, or the 
vasomotor nerves, causing a spasm of the muscles of the air passages. Hay 
lever is an affection which closely resembles bronchial asthma and alter- 
nates with it. 

Exciting causes are many; for example, enlarged bronchial glands, 
enlarged tonsils, adenoids, elongated uvula, and hypertrophied turbinates. 
The inhalation of irritants, such as dust, may irritate and provoke a spasm. 
Xot infrequently we find eczema existing at the same time or alternating 
with attacks of asthma. 

Gastro-intestinal disturbances are among the most frequent causes of 
asthmatic attacks. 

Pathology. — This is not known. Talma says : "The attacks are due 
to a spasm of the larynx, rarely to a spasm of the constrictors of the glottis. 
and that it is partly under voluntary control." Various theories are offered. 
One, that the attack is due to a swelling of the bronchial mucous mem- 
brane or to a catarrh of the bronchioles, or possibly to a spasm of the 
bronchial muscles. 

Symptoms. — Without warning, a spasm or shortening of breath comes 
on. most frequently at night. There is usually such oppression and dis- 
tr» ssed breathing that the child must sit up. Frequently the distress is so 
great that the child will grasp any object within reach. The shoulders are 
elevated and the head thrown back so that the accessory muscles of respira- 
tion are brought into play. The face assumes an anxious expression, and 
later becomes cyanotic. The eyes are prominent and the alae nasi widely 
dilated. A cold, clammy perspiration is usually present. The respirations 
are loud and wheezing, and are rarely increased in number. The inspiration 
is jerky, the expiration prolonged and laborious. There is very little or no 
thoracic expansion. The pulse is small and rapid. There is no fever, but 
we frequently have a subnormal temperature when the attack is prolonged. 
The extremities are frequently cold. After the attack there is exhaustion 
followed by sleep. An attack may last several hours, sometimes days. 
Percussion of the chest during the paroxysm shows lu/perresonancc. There 
may he either diminution or prolongation of the vesicular murmur. The 
whole chest has sibilant and sonorous rales and wheezing sounds. 



456 DISEASES OE THE BRONCHI, LUNGS, AND PLEURA. 

The diagnosis is easy; we must exclude spasm of the glottis, croup, 
tracheal stenosis, and neoplasm in the larynx. The absence of fever will 
easily differentiate this condition from inflammatory respiratory diseases. 

The prognosis is usually good, especially so at the time of puberty. 
Alter an attack a careful examination of the lungs, the kidneys, the nose, 
and the throat should be made, and the exciting cause, if possible, should 
be noted. 

Treatment. — Fresh air to thoroughly oxygenate the lungs will afford 
relief. Do not use steam or heat of any kind. The application of two or 
three dry cups over the front and also over the back of the chest repeated 
every six hours will relieve the spasm. Codein, 1 / 5 grain for a child 5 years 
old, repeated every two hours, or Dover's powder, 1- to 2- grain doses, 
repeated every three hours until relief is afforded. Chloral hydrate with or 
without bromide of sodium in doses of 3 to 5 grains once only should be 
given at night to promote sleep and as an antispasmodic. Surprising relief 
will be afforded by washing the colon with y 2 teaspoonful of powdered ox 
gall in 1 pint of water. The latter will not only empty the colon of faeces 
and gas, but will also relieve the mechanical pressure on the diaphragm. 
The bowels should be kept loose by giving salines. Iodide of sodium in 1- 
to 5- grain doses should be given at least one month after the acute paroxys- 
mal attacks have subsided. 

The diet should consist of milk, thin soups, and fruit juices. All 
starchy foods such as potatoes, bread, and cereals should be omitted. 
During convalescence, fruit, vegetables, eggs, fish, and meat may be given. 

Broncho-pneumonia (Catarrhal Pneumonia or 
Lobular Pneumonia). 

This disease derives its name from the fact that it usually exists as 
an inflammatory condition affecting small areas of the alveoli of the lung. 
Contrary to lobar pneumonia, this catarrhal form does not terminate by 
a distinct crisis. This disease is usually a sequela to or a complication of 
whooping-cough, measles, diphtheria, or typhoid fever. It is this form 
which is most dreaded in diphtheria and which rarely ends favorably. 
It does not occur in distinct cycles, nor does it run a distinct course. One 
child may suffer with a broncho-pneumonia extending over ten days or 
two weeks. Another child with the same form and severity of the dis- 
ease may suffer from eight to ten weeks. Thus this disease may be con- 
sidered to be of a distinct wandering t}^pe. This disease does not depend 
on seasonal changes, although the greatest number of cases are met with 
in the spring and fall. 

Etiology. — By far the greatest number of catarrhal pneumonias may 
be found in those children offering the least resistance. Such cases are 



UliOM'llo PNEUMONIA. 



457 



usually found in scrofulous, tuberculous, rachitic, and syphilitic children. 
When children have previously suffered from infections such as diphtheria, 
Bcarlel fever, measles, or typhoid fever, the} arc peculiarly predisposed to 
this secondary infection. It is for this latter reason that this disease is so 
fatal. In a series of fatal cases accompanying the various types of diph- 
theria seen by me at the Willard Parker Eospital, the large bulk suc- 
cumbed to this complication. This is due in a great measure to the 
devitalized condition of the body after a toxannic infection, such as is 
found in diphtheria. Whether or not this disease is contagious has not 
been definitely settled. 

Bacteriology. — We know that various forms of germs, such as the 
staphylococcus, streptococcus, the diplococcus pneumonia (Friedlander), 
the diplococcus (Fraenkel), and bacterium coli, are among the specific 
micro-organisms which have been found intimately associated with this 
disease. 




Fig. 138. — Diplococcus Pneumoniae ( Pneumococcus ) : (a) single diplo- 
cocci; (&) the same in chains (Wolf's double stain). Leitz ocular I, oil 
immersion 1 / 12 . (Lenhartz-Brooks.) 

Pathological Anatomy. — The tracheal and bronchial mucous mem- 
brane is intensely congested, and the lumen of the smaller bronchi filled 
with thick muco-pus, which adheres to the surfaces and is as tenacious as 
a pseudo-membrane. The lung at the seat of infection shows dark brown 
or brownish-red, infiltrated areas, sometimes of a bluish-red color. The 
surface of the pleura contains large or small hemorrhagic areas. They 
resemble a sort of hepatization, brownish, grayish, or yellowish-gray in 
color, and in some areas have purulent infiltrations. Sometimes the inter- 
stitial tissue is associated in this condition with a tendency toward cica- 
tricial formation. Sometimes the alveoli have an emphysematous disten- 
tion. The whole process seems to be a bronchiolitis associated with cir- 



458 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 




Fig. 139. — Purulent (Suppurative) Bronchitis. Peribronchitis and Peri- 
bronchial Broncho-pneumonia in a Child Fifteen Months Old. (a) Puru- 
lent; (6) mucoid bronchial contents: (c, c x ) bronchial epithelium infiltrated 
with round cells and partly desquamated (c 1 ) ; (d) bronchial wall contain- 
ing strongly congested blood-vessels and infiltrated with cells; (e) cellular 
infiltrated peribronchial and periarterial connective tissue; (f) septum be- 
tween the lung alveoli, partly infiltrated with cells; (g) fibrinous exudate 
in the alveoli; (h) alveoli filled with richly cellular, (i) with poorly cellular 
exudate; (k) transverse section of pulmonary arteries; {I) strongly con- 
gested bronchial, peribronchial and intra-acinous vessels. X 45. (Ziegler.) 

cumscribed atelectasis of the lung, from which hyperemia and infiltrations 
of tissne result. 

Symptoms. — The symptoms are those of a bronchial catarrh and a 
bronchitis. Associated with this there is the usual fever, restlessness^ and 
an increased frequency of respiration ; there is also dyspnoea. There is a 
distinct cyanosis affecting not only the face and lips, but frequently the 
nails. There is an anxious expression to the countenance. The ala? nasi 
participate in the respiration. The whole respiration seems to be super- 
ficial and brings every muscle into action. That there is an obstruction 
can easily be seen by an observation of the jugulum. by noticing the inter- 
costal space and also the epigastrium, which sinks at each inspiration. The 
frequency of respiration will sometimes be increased to TO or 80 per min- 
ute, and it is very jerky in character. The pulse-rate will suddenly rise to 
140 or 160. and frequently in some cases to 200 per minute. The tem- 
perature may be as low as 100° F. and gradually rise one degree or more 
each day. It may reach 104° or 105° R in the evening. The temperature 



BRONCHO-rNEUMON I A. 



459 



usually shows a morning remission of at least one or two and sometimes 
three degrees. 

Pictorial illustrations of broncho-pneumonia complicating measles and 
diphtheria will be found in their respective chapters. 



















WILLARD PARKER 


HOSPITAL 


















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X Reintubated. 

Fig. 140. — Louis B. Age 3 years. This very instructive case illus- 
trates the tolerance of the larynx for the intubation tube. In all twenty 
intubations were performed. The chart illustrates the tube coughed up four 
times in one day, thus requiring four distinct intubations in twenty-four 
hours. In spite of the fact that the case was septic from the beginning, and 
that the child had a broncho-pneumonia, the case recovered. In order to 
retain the tube and prevent its being coughed up, the caliber was gradually 
increased from a number three until an eleven to twelve tube was used. 
(Original.) 

Physical Examination. — The physical examination of the thorax shows 
moist rales, sibilant or sonorous rales, or coarse mucous rales, at times dis- 
tinct bronchial breathing accompanied by a metallic sound. Percussion 
will usually show dullness over small areas. While this may be due to the 
localized area of consolidation, it is quite possible that the dullness may 
also be attributed to enlarged bronchial glands in this region. When the 
disease terminates favorably the temperature falls, the pulse assumes a 
more regular character, the heart sounds, which formerly were feeble, ap- 
pear louder, stronger, and rhythmic. The cough will be more frequent, 
the respiration less frequent and not so superficial. Children who formerly 
were apathetic now appear to notice everything, and appear very sensitive 



460 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

on being handled, and especially so during an examination. The physical 
signs of a diffused bronchitis and the diffused areas of moist rales associated 
with the localized areas of bronchial breathing disappear. The bronchial 
breathing which existed before now becomes vesicular in character. The 
pulse, which f ormerry was greatly accelerated, and the respiration, which was 
very frequent, now both return to their normal state. The whole character 
of this affection has no specific rule, but drags along without a distinct ter- 
mination, differing from that condition so well known and described as 
croupous pneumonia. It is not rare to note an apparent cessation of the 
inflammatory condition in the pulse, respiration, and temperature, and to 
find that new inflammation has begun with more active symptoms than has 
been just passed through. 

We can therefore see that a broncho-pneumonia frequently is a con- 
tinuance of an inflammation which spreads from portion to portion and 
from lobe to lobe, and thus devitalizes the system. The symptoms affecting 
the gastro-intestinal tract and those of the genito-urinary organs are the 
same as found in croupous pneumonia. 

The differential diagnosis between catarrhal and fibrous pneumonia can 
easily be made by a comparison of the course which these diseases run. 
Catarrhal pneumonia commences with symptoms of a bronchial catarrh or 
a bronchitis. These same symptoms remain during the course of the disease. 
The symptoms do not have those of an acute character which characterize 
croupous pneumonia, but rather assume a chronic appearance. The great 
danger consists in the development of pus infiltration in the lungs, and 
it is only by the rapid emaciation that symptoms of miliary tuberculosis 
can be suspected. 

We can differentiate catarrhal pneumonia from atalectasis by the total 
absence of fever in atalectic conditions. 

Prognosis and Course. — The prognosis depends on the origin of this 
disease. If, for example, broncho-pneumonia is a sequela to measles, diph- 
theria, whooping-cough, scarlet fever, or typhoid, and the child has passed 
through a severe infection in which the corpuscular elements of the blood 
have greatly suffered, then the prognosis is grave. If, on the other hand, 
this disease commences as a primary affection and the child is in a fairly 
well-nourished condition, then the prognosis is good. The prognosis will 
chiefly depend on the amount of food that can be property assimilated and 
the care with which the case is nursed. The course is slow and tedious, 
and may develop tubercular pneumonia. 

The hygiene is very important in this condition. The prognosis of 
catarrhal pneumonia following whooping-cough, measles, or diphtheria will 
usually show that almost 70 per cent, of cases so affected are fatal. 

Treatment. — If the temperature is high, antipyretic remedies, such as 
the coal-tar products, are not indicated,, owing to their well-known de- 



miowiio PNEI MOXIA. 



461 



pressing effeci upon the heart. The author has never used them without 
seeing an ill effect. When they are used they should be combined with 
camphor or musk to counteract this well-known depression. The safest 
antipyretic measure in pulmonic affections is undoubtedly hydrotherapy. 

A cold compress applied over the thorax and repeated once every half-hour, 
not only acts as an antipyretic, but will stimulate the respiratory muscles 
and provoke deep inspirations. This will distend the smaller portions of 
the alveoli and will prevent ataleetasis pulmonum. If there is very great 




Fig. 141. — Diagram for Pneumonia Jacket Opened at Side. 




Fig. 142. — Diagram for Pneumonia Jacket Opened in Front. (Original.) 



dvspncea owing to the presence of viscid secretions, then an emetic is indi- 
cated. One of our hest emetics is sulphate of copper in 1-grain doses, re- 
pelled in an hour if necessary. Another emetic and one which is less 
irritating than the above is syr. scillae comp. in !/2 to 1 teaspoonful doses, 
repeated every half-hour until the desired effect is produced. Syrup of 
ipecac in doses of one teaspoonful, repeated every fifteen to twenty minutes, 
is also serviceahle. When a child has extreme dyspnoea and it is not wise to 
administer an emetic by month, then a hypodermic injection of 1 / 20 grain 
of apomorphia dissolved in five or ten minims of sterile water injected 
deeply into the subcutaneous cellular tissue will usually provoke emesis. 
If this dose is not effectual in fifteen or twenty minutes, then another 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

se of aponiorphia may be given. Tartar emetic in doses of grain, 

in sweetened water, may be given every hour until vomiting is produced. It 
is better not to change from one drug to another unless several doses have 
proven ineffectual. 

ed poultices are sometimes recommended when the secretions 
are very viscid. These have frequently proven efficacious in the hands 
of the author. In urgent dyspncea great relief can be afforded by the appli- 
cation of dry cups over the affected areas of the lun_ 

A pneumonia jacket consisting of cheese cloth, which is worn next 
to the skin, then a layer of cotton-wool, and the whole covered with oiled 
silk or oiled muslin will serve to prevent chilling of the surface. Figs 
141 and 142 show diagrams of these jacket- 
Internal diffusible stimulations, such as io-grain doses of carbonate 
of ammonia, repeated every hour, are serviceable. Liq. ammon. anisati. in 
doses of from 3 to 10 drops, repeated every hour, is one of our best dif- 
fusible stimulants. If symptoms of collapse appear then active alcoholic- 
stimulation must be resorted to. such, for example, as champagne, brandy, 
whisky, or wine ad libitum. In addition thereto, a sinapism over the front 
and back of the chest and mustard foot baths may be required. Hypo- 
dermic medication will frequently be found necessary, especially if the 
heart's action is feeble. One two-hundredth of a grain of nitro-glycerine 
injected hypodermically or caffeine citrate will sometimes work well. 
Strychnine sulphate in doses of V 200 grain, gradually increased, repeated 
every three or four hours or oftener. will stimulate the heart's action. An 
excellent heart stimulant is to give 1 drop of tincture of musk every hour. 
If the cough is very troublesome, especially at night, and the child is 
in a fair physical condition, then codeine in doses of x / 2(t to 1 / 10 grain for 
a child 1 year old. repeated every two or three hours, will relieve. Dionin is 
a remedy that has been used by the writer with considerable success in the 
treatment of various forms of cough in doses of x / 20 grain, repeated every 
three or four hours, for a child 1 year old. 

>:imulating expectorants such as syrup of senega, in doses of from 1 
to 15 minims, may be advantageous. The vital point to remember is to 
support the system with nourishment. If the child will not take food 
per mouth, then rectal feeding consisting of nutrient enemas is demanded. 
Water should be given freely during the course of a broncho-pneumonia 
t simulate the action of the kidneys. 

PtTLMOXAKY CtAXGBEVZ. 

This condition, fortunately, is very rare. 

Diagnosis. — This is made by the characteristic foul odor of the breath 
and the expectorated gangrenous material. I have seen a case of this kind 
during my summer service at the Willard Parker Hospital in a child that 



PLEl RISY 



463 



suffered with laryngeal diphtheria complicated by broncho-pneumonia. The 
Beptic condition dragged on for weeks. There was a very putrid odor to 
the breath. The child finally died of sepsis. As a rule the diagnosis ran 
only be made post-mortem. 

Treatment.— Restorative treatment, consisting of Light, nutritious diet, 
should be given and stimulants Liberally used. Steam inhalations impreg- 
nated with beechwood creosote will modify the odor. Creosote carbonate 
ran be given with the food in 5- to 10- minim doses, several times a day. 

Pleurisy. 

An inflammation of the pleura is by no means rare in children. Tt 
is found very frequently post-mortem, although no evidence of the same 
existed intra vitam. It may be a primary condition. 

There are two distinct forms of pleurisy usually seen: 1. Pleuritis 
sieea (dry pleurisy). 2. Pleuritis exudativa. The latter form can again 
be divided into (a) serous,, {b) sero-purulent. (c) purulent. (J) hemor- 
rhagic. 

The last mentioned is a rare condition. It is seen in traumatic con- 
ditions, in haemophilia, and occasionally when tuberculosis is present. 

Dry Pleurisy. 

This form of pleurisy usually follows an exposure to cold, although 
it may follow as a secondary inflammation to the lung. 
an exudation of fibrin only. 

Pathology. — The pleura is swollen and 
thickened, and there is an exudation of fi- 
brin. Adhesions frequently result from 
these bands of fibrin between the opposite 
pleural surfaces. The pleura loses its 
natural lustre. When the process ceases 
and the lymph is absorbed, the condition 
is called ''dry pleurisy." The fibrinous 
bands between the pleura costalis and pul- 
monalis usually leave permanent adhe- 
sions. 

Symptoms. — The disease is usually 
ushered in with high fever, which may reach 
104° or 105° F. Cough is usually present. 
It is a short, hacking, irritating cough. It 
is accompanied with pain. As a rule 
children cry during each coughing par- 
oxysm. There is no expectoration. A friction sound or a fine crepitant 
rale is heard over the affected area. There is vesicular breathing. The 



There is usually 



^q\\ oVtK'ae. g&g 




Fi<:. 14o. — Finer Curve in a Case 
of Dry Pleurisy. (Original.) 



464 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

percussion is rarely abnormal. The tongue is usually coated. The bowels 
are constipated. The urine is scanty. The surface of the body is dry and 
warm. There is usually a gradual increasing dyspnoea. The pulse-rate 
is increased; so also are the respirations. The symptoms resemble those 
of a pneumonia and can rarely be differentiated without a careful physical 
examination, There is usually pain on percussion over the affected area. 
The children do not wish to be handled, but prefer to lie quietly. 

The diagnosis depends on the symptoms above described. We must 
bear in mind the frequency with which pulmonary complications are asso- 
ciated. 

The prognosis is usually good, although adhesions frequently remain. 

Treatment. — Counter-irritation, such as cupping of the chest, the 
application of iodine over the affected area, or painting with cantharidal 
collodion, acts well. Strapping the chest with broad straps of adhesive 
plaster or the application of a very tight fitting bandage seems to sup- 
port the chest and relieve the cough. Calomel is indicated, especially if 
constipation accompanies this condition. Iodide of sodium, with very small 
doses of codeine, may be given at regular intervals to relieve pain. A full 
dose of codeine or morphine may be given at night if the cough is distress- 
ing or the pain acute. I have given from 1 / 30 to 1 / 20 grain of morphine 
hypodermically to a child 2 years old to relieve a severe cough. 



Pleurisy with Effusion (Pleuritis Exudativa). 

This secondary form of pleurisy is usually a complication or an exten- 
sion of the infection in pneumonia. It is frequently met with in influenza 
and in infectious diseases. I have frequently seen pleurisy with effusion 
in the scarlet fever wards of the Eiverside Hospital. I have also seen pleu- 
risy complicating tuberculosis and rheumatism in children. 

Bacteriology. — In some cases the streptococcus, in others the staphy- 
lococcus, is present. A diplococcus has also been found and believed by 
some to be the cause of pleuritis. The pneumococcus has been found pres- 
ent, so that it is difficult to state which pathogenic microbe is the true cause 
of this condition. Whether this microbe gains entrance to the pleura from 
the lung by inhalation or through the skin, or whether the tonsil is the 
means of entrance of the pathogenic bacteria causing this disease, has not 
been definitely determined. We know that suppuration in other parts of 
the body, as, for example, in the abdomen or in the spine, can frequently 
carry microbic elements to the pleura and thus directly transmit the infec- 
tion. Pyogenic bacteria may be carried to the pleura through the lymph 
channels and by the circulation. 

Pathology. — This form of exudative pleurisy is the one most frequently 
encountered. We rarely find both sides involved, although a double pleu- 



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144. — Fever Curve in a Case of Pleurisy 
with Effusion. (Original.) 



s by do means rare. The pathological condition is practically the same 

scribed in the chapter on "Dry Pleurisy." In tins condition we have 

more or less serous effusion. The serum may be clear, i( may be bloody, or 

it may be turbid. Serous effusions round in a healthy child arc usually 

bed. Adhesions arc frequently left in this form of pleurisy. 

Symptoms. — The fever 
may be high or low. Fever 
and general malaise accom- 
panied by a hacking cough 
wilJ frequently be the 
only symptoms. I have 
frequently seen children 
brought to my clinic with 
the history of a cough, no 
expectoration, anorexia, with 
general weakness and ema- 
ciation, in whom a pleurisy 
with a large effusion was 
detected. 

Diagnosis. — The diag- 
nosis in very young children 
is at times difficult. It can 
only be made by a most careful physical examination of the chest. 

Physical Signs. — Before the effusion is marked, and during its absorp- 
tion friction sounds are heard over the inflamed area. After the effusion 
is present there are no friction sounds. There are an absence of rales, dis- 
tant bronchial breathing, and flatness on percussion. There "is diminished 
breathing, so that the voice or the cry of the child will appear very distant. 
At the level of the fluid the voice has a tremulous sound, known as 
wgophony. There is a bulging of the intercostal spaces. The breathing is 
bronchial or tubular. Xot infrequently the heart is displaced. A careful 
inspection of the chest will show that there is a loss of motion on the 
affected side during respiration. 

In some cases the diagnosis depends on the result of an exploratory 
puncture with a clean (aseptic) needle having a large caliber. One of the 
best needles for this purpose is one similar to that used for the injection 
of antitoxin. A puncture should be made after washing the skin with 
soap and water followed by alcohol or ether. The needle is then inserted 
about one inch. Sometimes it is necessary to make several exploratory 
punctures in order to find the liquid, especially so in the encapsulated form 
of pleurisy, where a small area is involved. After withdrawing the liquid 
the character of the same should be determined by examining it under the 
microscope. If pus corpuscles are found we should insist on an operation. 

00 



466 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



as no other treatment will be satisfactory. Not infrequently a serous effu- 
sion will be absorbed by the exploratory puncture, so that the puncture is at 
times a very valuable therapeutic adjunct. 

Treatment. — Firm strapping of the chest with bands of adhesive 
plaster is useful; 5- to 15- grain doses of iodide of sodium, according -to 
age, may be administered three times a day in milk, soup, or broth. Fresh 
air should be constantly permitted. If pain is absent gentle a but long 
inspirations and expirations (pulmonary gymnastics) are worth trying. 
By properly exercising the lungs we can stimulate nutrition to the parts 
and frequently assist in the absorption of an effusion. 




Fig. 145. — Diagrammatic Illustration of Heart and Lungs in a Left- 
sided Pleuritic Effusion, a. Heart. 5. Compressed lung, area of bronchial 
breathing and crepitant rales, c. Effusion. (Original.) 

Dietetic Treatment. — Xo matter what form of treatment is instituted 
nothing will avail so much as proper feeding. The dairy products — milk, 
eggs, and cheese — in conjunction with cereals and fruits, should form the 
bulk of the food ordered. Concentrated soups and broths are also useful. 



Empyema (Purulent Pleurisy). 

Etiology. — As a rule we find this disease following pneumonia or pleu- 
risy. It is a favorite complication of the infectious diseases, so that after 
a pneumonia in an acute infectious disease we must not be surprised to find 
an empyema. 



EMPYEMA. 467 

Bacteriology. — The bacteria most frequently found arc the strepto- 
coccus, the staphylococcus, and the pneumococcus. Rarely has the tubercle 
bacillus been found. 

Pathology. — The surface of ihe pleura is covered with fibrin and pus 
and the cavity filled with a purulent exudate, the result of this inflamma- 
tion. The pus settles to the bottom of the pleural sac. 

infrequently both pleurae become involved, although the rule is 
to find hut one pleura or part of it affected. When not treated the pus may 
rupture into the lung or burrow externally through an intercostal space 

Symptoms. — The most pronounced symptoms are flatness on percussion 
and diminished respiratory sounds. Sometimes they are totally absent. 
is also a loss of the vocal fremitus. At the level of the fluid ihe voice 
tremulous quality known as wgo phony. 

Above the fluid the breathing is broncho-vesicular due to the com- 
d lung. Pleurothotonos is sometimes seen. 

There is an absence of expansion of the chest on the affected side. 
When this condition exists on the left side it may displace the heart. 

I rely upon the examination of the blood, in addition to the physical 

- given, as an important guide in deter miming the presence of pus in the 
system. See article and illustration of "Blood Reaction of Pus;' in the 
chapter on "Blood" 

Diagnosis. — If the fever continues after a ease of pneumonia, or pain 
in the chest persists accompanied by dypsncea, cough, and sweats, then 
empyema should be suspected. 

When the disease progresses the temperature frequently returns to 
normal or nearly so. The child shows symptoms of general exhaustion, 
emaciation, and is extremely amende. Diarrhoea is a frequent symptom in 
this condition. 

The physical signs above noted are usually positive. When there is 
any doubt, and in order to confirm the symptoms pointing to an empyema. 
an exploratory puncture should be made. 

If the needle is sterile and sharp and the surface to be punctured is 
rendered aseptic, then there is no risk in making one or more punctures to 
aid in establishing the diagnosis. 

Choice as to V^licre the Xeedle is to be Introduced. — My plan has always 
been to find by percussion the area having the greatest dullness or flatness, 
and insert the needle after noting the following : — 

Points to be Xoted while Making an Exploratory Puncture. — The skin 
should be washed with soap and water, dried, and again washed with alcohol, 
and lastly with ether. The needle should be boiled about five minutes before 
being used. 

If the needle is introduced on the right side, due allowance must be 
made for dullness in the region occupied by the liver. Do not introduce 



468 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 

the needle too near the region of the spine, but choose rather an intercostal 
space in the axillary line or preferably below the scapula on either side. 
If the needle is introduced on the left side do not push it too forcibly nor 
too deeply or haemorrhage may result. Sometimes the fluid is fibrinous and 
will not readily enter the caliber of the needle. If the needle is plunged 
too far and enters a dilated bronchus, due allowance must be made for a 
purulent secretion which should not be mistaken for empyema. 




Fig. 146. — Illustrating a Severe. Localized, Right-sided Empyema. Two 
ribs were resected. The child made a complete recovery. The thorax shows 
very slight deformity after the operation. (Original.) 

Prognosis. — This depends upon the general condition at the time of 
the operation. If the tubercle bacillus is found in the pus the prognosis is 
bad. The longer the disease existed the more doubtful the prognosis. If 
the condition is a sequela to a pneumonia or a pleurisy then the prognosis 
is good. 

Course. — The tendency of empyema in a child is to recovery. Out of 
20 cases operated by me, 18 recovered in four to five weeks. One case 
recovered after six months of continued surgical treatment, and was op- 
erated three times. One case was ill over two years, tubercle bacilli being 
found. This case belonged to the tuberculous type of empyema. 



EMPYEMA. 469 

Surgical Treatment. — When pus is located, the indication is to remove 
it. An incision should be made at least two inches long through the skin, 
and parallel with the rib. If the pus is thin in character a simple inter- 
costal incision carried into the pleura will evacuate the same. If the pus 
contains fibrinous coagula, it is better to resect one or two ribs. Care must 
be taken to preserve the periosteum in resecting the ribs. By this latter 
method we have complete drainage, and if the case is treated on general 
aseptic principles with drainage, gauze, and restorative treatment, the out- 
come is usually good. 

Points to be noted in empyema cases: — 

1. Anaesthetic. — Do not use general anaesthesia if cyanosis, marked 
dyspnoea, or other severe toxic symptoms are present. 

Local anaesthesia, such as chloride of ethyl or cocaine, can be used. 
I have frequently operated with the aid of chloride of ethyl. 

2. Regarding Antisepsis. — WTien pus is located we must resort to the 
usual details of asepsis and antisepsis. The instruments should be rendered 
thoroughly aseptic and the child should be given a bath on the day of 
operation in addition to a thorough scrubbing of the seat of operation. 

The physician, if a general practitioner, should be extremely careful 
and not operate if he has been in contact with an acute infectious case; 
neither should he operate if he has a case of erysipelas or diphtheria under 
his care. 

While the pus is being evacuated, turn the child from side to side, 
to empty the pleural cavity. If the heart' s action is poor this should not 
be done. 

A large-sized drainage tube should be inserted into the wound. The 
pleural cavity should not be washed with any fluid. Some authors advise 
using warm salt solutions. It is important to have a cross-section of rubber 
tube or a large safety pin attached to the drainage tube, otherwise, as has 
already happened, the tube may be lost in the cavity. 

The following case will illustrate peculiar symptoms shown in some 
cases of empyema: — 

A male child, 4 years old, was brought to my office by Dr. M. Freid, with the 
following clinical history: The child's appetite is poor. He does not sleep well, and 
has a peculiar waddling gait. The left shoulder blade protrudes so that a decided 
deformity is noticeable. There was no further history. 

An examination of the child showed marked emaciation. Temperature 100 4 /»° 
F., pulse 120, respiration 38, breathing labored, heart sounds weak but clear. On 
percussion there was marked dullness and flatness over the central and upper lobe 
of the lung on the left side. An exploratory puncture made about the eighth inter- 
costal space showed pus. Owing to the weakened state of the child it was 
necessary to operate without an anaesthetic. Ethyl chloride was used, an incision 
made, and two ribs resected. Thorough drainage was maintained with the aid of a 
drainage tube, and with the addition of restorative treatment, the case made an 
uneventful recovery. 



■■ 



470 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 



Treatment. — The treatment consists in building up the system with 
tonics of iron, hypophosphites, codliver-oil, malt, sea-salt bathing, and 
fresh air, in addition to a nutritious diet, of which milk, eggs, and cereals 
should form the bulk. 

Stimulation will be urgently required. In other words, our aim should 
be to build up the body to withstand the shock of the operation, and at the 
same time to nourish and restore the general weakened condition. 

After-treatment. — Strict asepsis. Change dressings daily. Use clean 
drainage tube and fresh gauze. Eemember the danger of iodoform poison- 
ing in using large strips of iodoform gauze. 

Give nutritious food. Sometimes a change of air to the mountains or 
seashore will aid in recovery. 

Eemember that 10 per cent, of all cases in which a simple incision 
is made do not require after-treatment. Ninety per cent, of cases require 
resection of the ribs and frequently additional surgical treatment for chronic 
empyema. 




Fig. 147. — James Apparatus for Expanding the Lungs in Empyema. 

James Apparatus. — Pulmonary gymnastics, such as inspiration and 
expiration, should be frequently practiced to aid in the expansion of the 
lung after an operation for empyema. A clever device is known as the 
James apparatus, by which a colored liquid can be blown from one bottle 
into another. This may be given to the child as a toy, and is very valuable 
as a means of producing deep inspiration and expiration. 



Chronic Empyema. 

Neglected cases or those of long standing frequently require additional 
treatment. Adhesions will frequently form preventing the normal expan- 
sion of the lung. A small opening or sinus containing exuberant granula- 
tions will be seen. In some cases seen by me pus has oozed for months. In a 
case of this kind nothing will do as well as a radical operation such as 



TUBERCULAR EMPYEMA. 471 

Estlander recommended (thoracoplasty). The adhesions must be broken 
up and thorough drainage allowed. When such a radical operation is per- 
formed, deformity usually follows. These cases belong to the surgeon. 

Tubercular Empyema. 

This condition while rare has been seen by me twice during the last 
five years. It is found in families where tuberculosis exists. We must 
bear in mind that a tubercular empyema may be the complication of what 
was formerly a non-tubercular type. 

Environment and heredity play an important part in the etiology of 
this condition. Just as a tuberculosis may follow the broncho-pneumonia 
of measles, so I believe that tubercular empyema may also develop. The 
following case will illustrate this condition as seen by me in consultation 
in New York City: — 

M. J., 5 years old, was referred to me by Dr. Mehrenlander, with a history of 
cough, fever, and emaciation. The diagnosis of empyema was made and an 
exploratory puncture showed the presence of pus. With the assistance of Dr. 
Mehrenlander I performed a thoracotomy. As there were thick croupous masses, 
two ribs were resected and a drainage tube inserted. In this case the wound 
discharged several months and an examination of the pus showed the presence of 
tubercle bacilli. With the aid of fresh air and restoratives, such as codliver-oil, 
creosote carbonate, and special attention to the out-door life, the child recovered. 

Family History. — The child's father and mother are living. Their occupation 
is janitor and janitress in a tenement house. They receive in compensation for 
services free rent, so that gives them very unsanitary surroundings. The bedrooms 
are dark and very unsanitary. An older brother, 17 years of age, has acute apical 
tuberculosis. This older brother when brought to me for a slight cough showed 
no visible evidence of disease, in fact he appeared well nourished. His sputum con- 
tained tubercle bacilli. We therefore have in the two cases just described a tuber- 
cular empyema associated with family tuberculosis. The coexistence of empyema and 
a family history of tuberculosis strengthened my opinion, that living under the same 
unsanitary conditions and associating together, these cases were most probably 
transmitted or communicated. 



PART VII. 

THE INFECTIOUS DISEASES. 



CHAPTER I, 



FEVER. 1 



This is a pathological process generally caused by the poisonous prod- 
ucts of bacteria, and characterized by a rise of temperature above the limit 
of the daily variation. It is further associated with an increase in the fre- 
quency of the heart and the respiratory movements, often with an increase 
in excretion of urea and ammonia in the urine and a diminution in the 
alkalies and C0 2 in the blood. 2 

Some authors state that the cause of fever is the action of bacterial 
poison or of other substances on the heat centers, and that antipyretics or 
drugs which reduce the temperature in fever, do so by restoring the centers 
to their normal state by preventing the development of the poisons, aiding 
their elimination, or antagonizing their action. Thus it has been stated 
(supporting the latter view) that if the basal ganglia have been cut off 
(by section of the pons) from their lower nervous connections, fever is no 
longer produced by injection of cultures of bacteria which readily cause it 
in an intact animal — while antipyrine has no influence on the temperature. 
These experiments were reported by Sawadowski. 

Some observers have been unable to find any clear evidence of heat 
centers ; that is, of localized portions of the central nervous system specially 
concerned in the regulation of the body temperature. 

It is almost certain that some pyrogenic or fever-producing agent — 
cocaine, for example — acts indirectly through the brain or cord, and likely 
others affect directly the activity of the tissues in general, just as some 
antipyretics or fever-reducing agents, such as quinine, seem to act imme- 
diately upon the heat-forming tissues, while antipyrine affects them through 
the nervous system. 

Variations in Temperature. 3 — The temperature of the body is not con- 
stant. It varies with the time of day, with eating, with age, somewhat 
with violent changes in the external temperature (hot or cold baths), and 
even possibly Avith sex. 



1 For treatment of fever, see pages 511 and 512. 

2 Stewart's Physiology, p. 443. Article on "Animal Heat." 

3 The temperature as a diagnostic aid is described in Part I, page 11. 

(472) 



FEVER. 473 

The lowest temperature is recorded between 2 and 6 a.m. The highest 
at 5 to 8 p.m. There is a corresponding fluctuation of pulse-rate at the same 
time of day. 

Taking of food increases the temperature, but not more than one-half 
of a degree in healthy individuals. Entrance of food into the body in- 
creases metabolic activity, no doubt, through entrance of products of diges- 
tion into the blood. 

Sex. — Females usually have higher temperature than males. 

Relation of Age to Temperature. — There is a relative imperfection 
between heat regulation in old people and young children; thus, young 
children are more liable to sudden increase in temperature as well as to 
chills. A fit of crying will send up the temperature. Sudden fright (slam- 
ming a door) will send up the temperature (J. L. Smith). 

Mosso reports that the rectal temperature rose three degrees in a dog 
rendered helpless with injections of curare. When injections of strychnine 
were given, this latter (strychnine) no doubt irritated the nervous system. 
He found that the presence of food was enough to cause the rise in the 
temperature of the dog. 

Thus we find that the usual fever-causing factors are : — 

1. Toxins. 

2. Ferments. 

3. Products of waste which are absorbed in the lymphatics (detritus). 

We know that the regulation of the heat is brought about by the cen- 
tral nervous system, and we also know the influence brought about by the 
vasomotor (nervous system) in dilating and contracting the capillaries. 

The discovery of Aronsohn and Sachs, that by traumatism or irritation 
of the corpus striatum, an elevation of temperature is produced, is still 
a question, doubted by many distinguished observers. But it certainly 
does look as though a certain center or centers exist which influence the 
body temperature. 

Knowing then that other agencies besides disease cause an elevated 
temperature, the question arises : are we justified in designating every rise 
of temperature as "fever?" Hardly. An elevation of temperature (above 
normal) should be designated as "hyperthermia." We know that the 
fever is caused by the absorption of infectious products which later cause 
a breaking down and loss of the red blood corpuscles, breaking down of the 
tissues, and disintegration of albumin and its compounds, and produce 
symptoms pointing to distinct disorders in the human economy. Some 
authors have described fever under two headings or divisions: — 

1. Septic. 

2. Aseptic. 

As an example of a septic fever, we have that chronic poisoning of the 
human organism which takes place in chronic pulmonary tuberculosis, and 



474 THE INFECTIOUS DISEASES. 

even in this latter toxsemic process we find sudden rises of temperature, 
which must be explained by emotional means, or rather by nervous causes. 
In a tuberculous patient whose system is overwhelmed with toxins (chronic 
and continuous poisoning) we can readily understand why the thermic 
centers as well as all other centers could be easily influenced to cause a 
sudden rise in temperature responding to a slight emotion or fright. 

Let us now consider so-called "nervous" or, as it has been designated, 
"hysterical fever." The latter term we owe to the French authors (Pomme, 
Toussot, Baillon, Eiviere). By this we mean a febrile condition which is 
not caused by any inflammatory or other disease agency, and which is 
found in either very nervous, neurasthenic, or hysterical patients. 

Broussois (France) opposed this theory and believed this condition 
due chiefly to inflammatory changes in the ovary and uterus. 

Briquet showed by careful examination the fallacy of the foregoing 
statements in a series of noteworthy investigations. 

In 1888 Chaveau, in Paris, wrote a careful dissertation called "Fievre 
Hysterique," and divided this condition into several distinct groups. A 
characteristic point is the absence of gastric disturbance (digestive), show- 
ing that it was not a malignant disturbance. 

Chaveau looked to the cause of his cases in an abnormal excitation of 
the thermic center in sensitive (nervous) individuals. An accompanying 
factor he believes to be either traumatic or psychic disturbances. 

Wunderlich (Germany) long ago called attention to the fact that 
listeria influences the temperature, and that in hysterical neurosis we find 
sudden elevations of temperature. It is a remarkable fact and one noted 
by many others, that one side of the body shows this high temperature 
without any pathological condition manifesting itself. 

Eosenthal (Vienna) found distinct localized areas of redness with 
marked rise of temperature in this area, but found no general febrile 
disturbance. The patient was decidedly hysterical. Strumpell agrees that 
he has found very high temperatures, irregularly, but believes the patients 
simulated their marked hysterical and irritable condition. 

Bwald (Berlin) agrees that hysterical patients can produce high fever 
by reason of their excitement. 

Hale White (England) doubts that the thermogenetic functions should 
cause high fever, and cites instances which were known as hysterical paral- 
ysis. 

Cleman reported in the Clinical Society of London, 1883, a case of 
hysterical fever, showing the enormous temperature of 111° F. at various 
times. 

Hale White believed that a mistake in reading the thermometer was 
made. 

Ughetti believes hysterical fevers exist, and cites as proof of the same 
fever in course of hysteria, chorea, epilepsy, and Basedow's disease. 



FEVER. 



475 



The greatest scientific contribution on this subject has certainly been 
the work of A. Sarbo in the University of Psychiatric and Nervous Dis- 

- in Budapest. 1 He believes as a result of experimental study, that 
the causation of fever should be looked forward to in the "central nervous 
system/' and that the experimental discoveries of the thermic and vaso- 
motor centers seem to confirm this. This author believes that fever, which 
has no organic lesion as a cause, should be called functional fever, which 
is a condition found in hysteria, the latter, a functional neurosis. It is 
interesting to record that Debone increased the temperature by suggestion 
to 101.2° F. or 3S.5° C. 

Krafft-Ebing records temperatures by suggestion as high as 106.4° F. 

Sarbo concludes by sa3 7 ing that from his clinical observations a distinct 
hysterical fever exists. 

Hysterical fever can simulate by its exacerbation and remission such 
diseases as typhoid, malaria, tuberculosis, and meningitis. 



Table No. 60.— Showing ih 


e Ratio of 


Mortu 


nty f 


rom Infectious D 


'sease* of Children 


Under Two Years of Age in New York City. 






Males. 














! 


Tubercular Diseases . . 


294 


678 322 304 198 297 


253 


252 


256 


210 


219 192 


Diphtheria and Croup . 


333 


343 361 39S 376 377 


337 


278 


201 


195 


219 236 


Measles 


200 193 j 317 


142 


204 251 218 


133 


188 


141 


1 55 90 


Whooping Cough . . . 


164 137 ; 122 


205 


74 


172 154 


99 


167 


132 


107 53 


Scarlet Fever . . . 


44 145 


102 


64 


67 


50 


46 


66 


66 


37 


62 58 


Phthisis Pulmonalis . . 


54 42 


61 


58 


49 


74 


50 


52 


47 


53 


50 44 


Typhoid Fever .... 


3 4 


5 


3 


3 


5 


2 





1 


1 


4 3 


Year 


1890 1691 i 1892 
1 


! 

1898 | 1894 


1895 


1896 


1897 


1898 ! 1S99 

i 


1900 . 1901 


Fema es. 






















Typhoid Fever 


2 3 


4 


2 


2 


1 


2 


2 


1 





2 2 


Phthisis Pulmoualis . . 


54 41 


50 


46 


35 


53 


42 


40 


25 


41 


21 35 


Scarlet Fever . . 


54 ! 121 


113 


63 


53 


53 


37 


48 


58 j 40 


28 56 


Whooping Cough . . . 


212 : 140 


162 


221 


121 


219 


179 


139 


186 ! 139 


123 72 


Measles 


240 232 


261 


121 


1S2 


265 221 


134 


136 1 125 


157 72 


Diphtheria and Croup . 


259 287 


289 283 410 


316 j 262 


287 


136 201 


172 200 


Tubercular Diseases 


228 361 251 j 243 1 214 j 220 j 201 


223 


213 213 


189 146 



Note. — Various statistics and temperature charts were procured from 
the wards of the Riverside Hospital with the kind assistance of Dr. Watson, 
the resident physician. 

I am also indebted to Dr. Henry L. Lynah for similar courtesies in the 
wards of the Willard Parker Hospital. 

I am indebted to Dr. William H. Guilfoy, Registrar of the New York 
Health Department, for many courtesies in the preparation of the statis- 
tics of the various infectious diseases. 



1 Published in the Archiv fur Psychiatrie in 1891. 



■ 



476 



THE INFECTIOUS DISEASES. 



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TABLE Ol- [NFE< TI01 S DISEASES. 



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478 



THE INFECTIOUS DISEASES. 



Table No. 62. — Showing Ratio of Mortality from Infectious Diseases in Children 
Between the Ages of Two and Five in New York City. 



Males. 


























Diphtheria and Croup . 


430 


494 


580 


617 


731 


477 


405 


350 


190 


240 


297 


275 


Scarlet Fever ... 


99 


319 


244 


142 


127 


149 


106 


127 


119 


83 


77 


151 


Measles . . : 


105 


95 


113 


47 


70 


105 


118 


52 


58 


45 


67 


48 


Tubercular Diseases . . 


82 


72 


81 


92 


82 


86 


98 


86 


85 


89 


90 


67 


Whooping Cough . . . 


40 


28 


32 


'39 


26 


38 


29 


31 


28 


25 


32 


11 


Phthisis- Pulmonalis . . 


22 


19 


24 


26 


24 


22 


13 


13 


9 


24 


29 


20 


Typhoid Fever 


5 


9 


7 


4 


2 


3 


7 


5 


4 


2 


5 


8 


Year . . .... 


1890 


1891 


1892 


1893 


1894 


1895 


1896 


1897 


1898 


1899 


1900 


1901 


Females. 


! 














n. 








Typhoid Fever 


4. 8 


2 


4 


3 


3 


3 


5 


3 


2 


6 


7 


Phthisis Pulmonalis 


21 16 


23 


27 


20 


16 


21 


23 


19 


26 


18 


18 


Whooping Cough . . 


56 ' 39 


45 


59 


43 


50 


57 


31 


51 


46 


41 


19 


Measles . . . 


87 1 102 


122 


59 


85 


132 


116 


50 


49 


46 


55 


40 


Tuberculosis . 


85 ! 74 


77 


72 


83 


98 


79 


66 i 65 


80 


65 


71 


Scarlet Fever 


102 J 302 


235 


127 


136 


105 


105 


124 151 


81 


62 


138 


Diphtheria and Croup 


432 i 465 


494 


612 


701 


449 


430 


254 203 


257 


279 


273 



Table No. 63. — Showing the Ratio of Mortality from Infectious Diseases of Children 
Between the Ages of Five and Ten in New York City. 



Males. 


























Diphtheria and Croup . 


151 


163 


160 


226 


249 


146 


130 


128 


65 


74 


131 


95 


Scarlet Fever 


55 


136 


118 


69 


58 


42 


53 


69 


56 


38 


38 


100 


Tubercular Diseases . 


31 


38 


33 


44 


51 


34 


41 


43 


37 


29 


35 


47 


Phthisis Pulmonalis 


22 


30 


24 


35 


35 


21 


24 


28 


28 


33 


29 


30 


Measles .... 


16 


18 


18 


9 


20 


15 


16 


6 


6 


16 


15 


14 


Typhoid Fever ... 


9 


12 


10 


12 


9 


6 


11 


7 


9 


3 


11 


6 


Whooping Cough 


1 


3 


2 


5 


3 


5 


6 


2 


3 


1 


4 


1 


Veab 


1890 


isyi 


1892 


1S93 


1894 


1895 


1896 


1S97 


1898 


1899 


i 

1900 ; 1901 


• Females. 






















| 


Whooping Cough . . . 


6 


4 


8 


12 


5 


10 


10 


1 


6 


6 


9 ! 2 


Typhoid Fever . . . 


8 


14 


14 


7 


- 6 


6 


13 


9 


7 


8 


6 | 4 


Measles . . 


16 


12 


2 7 


11 


15 


20 


16 


12 


5 


5 


15 i 6 


Tubercular Diseases . . 


34 


46 


40 


42 


49 


42 


41 


38 


36 


47 


38 | 36 


Scarlet Fever 


45 


165 


131 


68 


72 


57 


52 


59 


56 


48 


32 1 102 


Phthisis Pulmonalis . . 


70 


62 


61 


67 


47 


53 


56 


41 


48 


50 


48 I 53 


Diphtheria and Croup . 


152 


182 


185 


283 


275 


181 


167 


170 


103 


86 


138 115 



Table No. 64. — Showing Percentage of Deaths from Infectious Diseases in Children 
Under Ten Years, from 1890 Until 1902, in New York City. 





MALES 


FEMALES. 




Died 


Per cent. 


Died. 


Per cent. 


Typhoid Fever 


317 


.006 


252 


.004 


Phthisis Pulmonalis 


1,228 


.024 


1,386 


.027 


Whooping Cough . . 


1,928 


.038 


2,545 


.050 


Scarlet Fever . . 


3,357 


.066 


3,104 


.061 


Measles ... 


3,394 


.066 


3,294 


.065 


Diphtheria and Croup 


10,576 


.293 


10,117 


.200 


Tubercular Diseases 


4,857 


.096 


4,177 


.082 



CHAPTEE IT. 

IXFLIKNZ A (LA GRIPPE). 

Commonly known as "grip" or "01)1(1011110 catarrhal fever." 
Tin's is an acute infectious disease with which catarrhal disturbances of 
the respiratory or gastro-intestina] organs are usually associated. There 
is also a profound nervous disturbance with marked perspiration and very 
high fever. 

The disoaso occurs epidemically, spreading from case to case with 
great rapidity, so that it was formerly attributed to meteorologic condi- 
tions. It is for this reason known and described by the Germans as a 




Fig. 148. — Influenza Bacilli. Sputum smear, stained with dilute Ziehl's 
solution. Bacilli chiefly intracellular, most of them sIioav thickened ends. 
X800. (Lenhartz-Brooks.) 

"Blitzkatarrh." The disease occurs most frequently in cold and damp 
weather, and frequently attacks the same person several times. 

Bacteriology. — The disease is caused by a very small bacillus, about 
0.8 micro-millimeter long and 0.4 micro-millimeter broad. 

This bacillus was first discovered by Pfeiffer, in 1892. It stains very 
intensely at the ends and resembles a cliplococcus. 

In the mucous membrane of the nose, throat, and lungs we find the 
greatest number of bacilli ; thus, it is reasonable to suppose that the in- 
fection takes place through the respiratory tract, and in this manner the 
germs gain an entrance into the body. 

The bacillus of Pfeiffer only is present in influenza. The poison gen- 
erated by this germ resembles a group of bacterial proteins, described by 
Buchner. Such poisons occur within germs and are excreted, but only 

(479) 



480 THE INFECTIOUS DISEASES. 

to a limited extent, in the media in which they grow. Examples of these 
germs are the diphtheria and tetanus bacilli. Such toxins affect the cen- 
tral nervous system very powerfully. Thus we find severe nervous depres- 
sion in the course of an attack of influenza, just as we do in the course 
of a severe case of diphtheria. The influenza bacillus is frequently asso- 
ciated with other pyogenic bacteria. The tendency of mixed infection in 
the course of influenza is to generate pus. It is therefore a wise plan to 
examine the middle ear for possible suppurative conditions. 

Xot infrequently tuberculosis is associated with or follows a severe 
attack of influenza. 

Symptoms. — When children are old enough to complain, then one of 
the most frequent subjective symptoms will be either a violent headache 
or pains in the muscles of the body. In young children and nurslings 
violent vomiting, associated with diarrhoea, may be the initial symptoms of 
the disease. While fever usually accompanies an attack of influenza, there 
are many cases in which a subnormal temperature is present. As has been 
previously stated, chills or rigors are seldom or never present. 

Convulsions in young children are frequently a forerunner of an attack 
of influenza. The differential diagnosis between an attack of measles and 
influenza is sometimes quite difficult. Both commence with sneezing, 
coughing, and catarrhal symptoms, with suffused eyes, and an eruption 
resembling measles may frequently be found in influenza. 

Diagnosis. — The diagnosis of this disease is sometimes very difficult. 
If an epidemic exists, or if several members in a family are attacked with 
grip and the children suddenly exhibit symptoms of malaise or have a dis- 
ordered stomach, and show high fever without any apparent reason, then 
influenza should be suspected. If catarrhal symptoms associated with 
influenza present themselves, then such symptoms are of a more severe 
type than those usually seen in simple coryza. 

An eruption resembling scarlet fever, complicated by tonsillitis or 
pharyngeal symptoms, will baffle the diagnostic ability of the physician, 
but the presence of influenza in a house will aid in eliminating other dis- 
eases and assist in establishing the true diagnosis. Not infrequently a child 
will suddenly show high fever and diarrhoea, with severe nervous depres- 
sion, intense thirst, and typhoid tongue, with here and there small lenticu- 
lar spots which may so resemble typhoid fever that only the course of 
the disease and constant watching will aid in making a correct diagnosis. 
Where such symptoms exist we must resort to an examination of the urine, 
and it is here that the diazo reaction will render material assistance. In 
addition to the examination of the urine, the Widal reaction should be 
resorted to. If both the Widal and the diazo reaction are absent, and if 
the depression and catarrhal symptoms resembling influenza continue, 
then, and then only, should the diagnosis of influenza be made. The fever 



INFLUENZA. 



481 



is more irregular in the course of 
influenza than it is in typhoid, and 

usually shows an evening fall and a 
morning rise, which is the reverse 
of typhoid. The skin is usually 
very pale in typhoid and flushed in 
influenza. There are three definite 
types of influenza most usually met 
with in children: — 

1. That affecting the respira- 
tory tract. 

2. That affecting the gastro- 
enteric tract. 

3. That in which the brain and 
nervous system are largely affected. 

Respiratory Type. — When the 
respiratory tract is involved we usu- 
ally have either a pharyngitis, ton- 
sillitis, pneumonia, or a broncho- 
pneumonia. When a very young 
child shows severe broncho-pneumo- 
nia arjd there is a general toxaemia 
associated with it, then the prognosis 
is usually very bad. A very frequent 
complication in this condition is tu- 
berculosis; thus, if tuberculosis fol- 
lows a severe attack of influenza in 
a young child whose system is un- 
dermined from a long and tedious 
disease, then grave results may fol- 
low. 

Gastro-enteric Type. — In very 
young children this is the most fre- 
quent form of influenza. Vomiting 
and diarrhoea, usually accompanied 
by fever, will be found. The child 
will suddenly refuse to take the 
breast, if it is a nursling, or refuse 
to take bottle if it is hand-fed. It 
will also show great restlessness and 
seem dissatisfied and peevish. 
The sleep will be disturbed, so that 
insomnia is a very frequent symp- 
tom. In spite of careful dietetic 



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Fig. 149. — Case of Influenza Pneu- 
monia. Child about eight months old. 
Suffered severe prostration from the 
toxaemia. Note the very high pulse-rate. 
Treatment consisted in using steam im- 
pregnated with beechwood creosote, mild 
laxative and careful diet. Case recov- 
ered. (Original.) 



M 



482 THE INFECTIOUS DISEASES. 

treatment and a thorough cleansing of the gastro-intestinal tract, the child 
will show the same clinical picture in mid-winter as we are familiar with in 
the course of a severe type of summer complaint in mid-summer. Convul- 
sions are frequent, though not always present. Such children suffer 
severely, owing to the malnutrition and owing to the extreme exhaustion 
following a continued vomiting or diarrhoea, They lose flesh and resemble 
the atrophied condition following an acute summer complaint. 

Nervous Type. — This is usually the most serious form of the disease, 
involving, as it does, the brain and the nervous system. In this type we meet 
with extreme irritability, and if the child is old enough to complain then 
headache forms a prominent symptom, so also will pains in the limbs and 
in all the muscles of the body be complained of. Twitching is sometimes 
a marked symptom ; convulsions are very frequent. 

If the case of influenza is the only one in the family the physician may 
believe that he is dealing with a meningitis. Such symptoms as photo- 
phobia, stupor, coma, retraction of the head, are frequently present; 
the pulse is rapid, the temperature is frequently very high, although the 
usual temperature ranges between 101° and 103° F. "When severe toxaemia 
exists it is not infrequent to find a subnormal temperature. 

Complications. — The influenza bacillus has a tendency to develop pus; 
hence, a nasopharyngeal catarrh may extend through the Eustachian tube 
and develop mastoid. If influenza attacks the lung and fever persists, look 
for empyema. Be sure to examine the urine, as influenza may cause pyelitis, 
especially if the fever is of an intermittent character. The influenza 
bacillus may enter the frontal sinus through the nose and set up a 
meningitis, which may be of a suppurative character. 

J. Madison Taylor contends that neuritis rarely follows influenza in 
children, whereas it is a common sequela in adults. 

Nephritis occasionally complicates influenza. 

Milton Miller 1 reports 40 cases of influenzal nephritis taken from 
literature. He reports a very interesting case of a child that had persistent 
vomiting and slight diarrhoea; later on oedema of the limbs and suppres- 
sion of urine. 

The course of influenza in children is hard to define. Some children 
will be ill a week or ten days; others will show the evidence of systemic 
infection months after an attack commenced. For this reason every case 
of influenza should be carefully supervised during the convalescence. 

Prognosis. — This depends on the condition of the child prior to an 
attack. If, for example, an infant nursing at the breast is attacked with 
a severe form of influenza, then the prognosis may be reasonably good. If, 
however, the "bottle baby/' with an existing rickets, is attacked in a similar 
manner, then the prognosis is certainly much worse than it would be other- 



Archives of Pediatrics, January, 1902. 



IXTLfEXZA. 






s the general sy>teinic condition prior to the infection of tli- 
- __ ~t the probable outc-ome of the disease. On the other 

iild, having a severe form of influenza, complicated by 
middle-c; . with mastoid or cerebral complications, necessarily means 

a bad prognosis. The same role would apply to all complications following 
influenza, in which ex- 
haustion from a lengthy 
attack, besides the diffi- 
culty of properly feeding 
and sustaining life, would 
invite a fatal termination. 
The sheet anchor of 
- 

good condition of the 
heart, the exclusion of 
~- amplication, and 
the fact that the 
infant takes a reasonable 
quantity of food. A pro- 
gressive weakness of the 
heart or the devitalized 
of the blood from 

would mean a grave prog- 

:hus all would 

depend on limiting the 

rit of the disease and 
the avoidance of compli- 
cations. 

Treatment. — In a 
case of grip ft is advis- 
able to isolate the child 
affected from the other 
children in the family. 

: to isolation the 
child must be put to 
bed and kept warm. It is advisable to give a mustard foot-bath to 
stimulate the circulation, and follow this up by keeping either a hot-water 
bag or bottles of hot water to the feet If the head is very hot an ice-bag 
or cold, applied by ice-cold handkerchiefs to the head in the region of 
the fontanels, would be indicated. If high fever exists then 15 to 30 drops 
of sweet spirits of niter, repeated three times in intervals of one hour, will 
nly aid the kidneys, but also have a slight diaphoretic efl 



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i>ver and compare the steady heart's actio 
cated by the pulse. Child recovers. (Original.) 



a m a 
type of 



484 THE INFECTIOUS DISEASES. 

, A favorite formula of mine is tincture aconite rad., 1 drop, combined 
with spiriius mindereri, 1 /. 2 teaspoonful, freshly prepared, and kept in a 
cool place. The above to be given every hour until the temperature is 
reduced or until perspiration appears. 

The stomach and bowels require very careful attention in the gastric 
type of this disease; thus a good plan is to commence by giving a 
small tablet, containing 1 / 10 grain of calomel, with a little water, every 
hour for six doses, or until the effect of the calomel is manifested by the 
greenish stools. 

If the child is old enough then small pieces of cracked ice or ice cream 
may be given for several hours. If vomiting persists after the ice cream 
then nothing should be given by mouth for six hours. 

During such time, when there is severe irritability, medication may be 
given, either in the form of rectal suppositories, or, if possible, by hypo- 
dermic means. 

An ice-bag applied at the pit of the stomach will frequently arrest 
vomiting. An ether spray over the epigastrium for a minute will some- 
times relieve a persistent vomiting. 

Liquid food in a concentrated form, such as broths, soups and cereals, 
steak juice, raw beef juice, white of egg and water, or the yolk of an egg 
added to concentrated soup, is very nourishing if the stomach can retain 
the same. Calisaya is one of the best tonics. If the stomach is not irri- 
table nitroglycerine, in doses of 1 / 200 grain, will do good. 

Strychnine, persistently given, is indicated in the course of convales- 
cence just as it is indicated in diphtheria. 

Peptonized foods, chiefly milk and peptonized broth, may be neces- 
sary if we are dealing with a prolonged gastric type of the disease with sub- 
normal digestive power. When convalescence is established then syrup of 
hypophosphites, or phosphorus combined with codliver-oil, or the glycero- 
phosphate of lime, will be found advantageous. 

No matter how slight an attack of influenza has been encountered it is 
well, when convalescence is permanently established, to insist on a change 
of air to the South, if in winter, to such places as Virginia Bay, Old Point 
Comfort, or Florida, or if in the summer to places like Lakewood, or, 
better still, Atlantic City. If we have encountered a severe form of this 
disease with extreme emaciation and loss of tone, then a radical change of 
air to a more balmy and permanent climate, such as is found in Southern 
California or in New Mexico, should be recommended. 

If bronchial catarrh persists with expectoration, or if we are dealing 
with an incipient form of tuberculosis, following this attack of grip, then 
a change of air to Colorado, and out-door life, may be the means of arrest- 
ing the disease and effecting a cure. 

Alcoholic stimulation must depend on the individual case. If the 



INFLUENZA. 485 

infant assimilates milk, broth, cereals, and the pulse is good, then alcoholic 
stimulation is unnecessary. If, however, the pulse is weak and very little 
or no food is taken, then it may be necessary to give whisky, especially so 
it' the pulse is feeble and the heart shows signs of weakness. Champagne 
may be given if persistent vomiting, with exhaustion and heart strain, mani- 
fests itself. 

The value of coffee freshly made, to which some milk is added, must 
not be forgotten. Caffeine may be substituted if coffee is not at hand. 

Carbonate of ammonia, in doses of 1 grain for a child of 1 to 2 years 
old, repeated every two or three hours, will be useful as a stimulant during 
the course of extreme exhaustion following the respiratory type of this 
disease. 

To stimulate the circulation if extreme cyanosis or cold extremities 
persist, nothing will equal judicious massage. Cupping or other forms of 
depletion should not be practiced unless severe meningeal symptoms or 
constant convulsions demand the same. Dry cupping over the chest will be 
found useful to relieve the shortness of breath at the onset of pneumonia. 

In cupping it is advisable to use two cups anteriorly and four cups 
posteriorly at the same time. The pulse should be watched, and if any 
irregularity presents itself then cupping should be immediately discon- 
tinued. 

The depressing effects of the coal-tar products, such as antipyrine and 
phenacetine, should be remembered. If such drugs are used they must be 
combined with camphor or musk to counteract the depressing effect on the 
heart. 

The fever is rarely so high that we must resort to antipyretic drugs. 
I have seen good results from sponging the body with alcohol and water, 
or with acetic ether, repeated every hour or every half-hour if necessary. 
If the temperature persists a cool pack should be applied to the upper 
half of the body. This pack should consist of a sheet wrung out of cool 
water. The temperature of the cool pack is 80° F. These packs should 
be repeated every fifteen minutes if the temperature is 105° F. or over, 
and every thirty minutes if the temperature is 103° or 104° F. The same 
treatment should be continued until the temperature falls to 102° F. or 
lower. 

Iron may be necessary for months after an attack of influenza. The 
more simple forms of iron, such as neoferrum, are easily assimilated by a 
child. A preparation that the writer uses frequently is tinct. ferri. acet. 
seth., in doses of 5 to 20 drops diluted with water, three times a day. This 
form of iron is easily digested, will restore tone to the system, and increase 
the red blood-corpuscles if continued for some time. 



CHAPTEE III. 

PERTUSSIS ( WHOOPING-COUGH) . 

This acute infectious disease is caused by a specific micro-organism. 

Etiology. — The disease usually gains entrance to the body when the 
infant is in a subnormal condition. We must therefore expect to find the 
greater number of cases in tenement houses, and in the crowded districts 
of the poor. 

Whooping-cough is frequently associated with measles. 

Babies brought up by hand-feeding, so-called bottle-babies, surfer 
severel}, and are infected more readily than infants that are breast-fed. 



Table No 65. — Statistics: Deaths from Whooping-cough in Children Under 
15 Years in Old City of New York. 










Years 


l 

Year 


2 
Years 


3 

Years 


4 

Years 


Under 

5 
Years 


5-10 
Years 


10-15 
Years 


1890 


Males .... 
Females • . 




211 

274 


115 
133 


49 
79 


30 

33 


4 
17 


6 
6 


204 
268 


7 
6 




1891 


Males 
Females 




168 
183 


95 
96 


42 
44 


16 
29 


8 
6 


4 
4 


165 
179 


3 
4 




1892 


Males . 
Females . . 




156 
215 


71 
104 


51 

58 


18 
26 


9 
10 


5 
9 


154 

207 


2 
8 




1893 


Males 
Females 




249 

292 


122 
126 


83 
95 


25 
34 


9 
17 


5 

8 


244 

280 


5 
11 


1 


1894 


Males 
Females . . 




103 
169 


57 
76 


17 

45 


17 

27 


5 
9 


4 

7 


100 
164 


2 

4 


1 
1 


1895 


Males . . 
Females 




215 

279 


114 

127 


58 
92 


24 

30 


8 
10 


6 
10 


210 

269 


5 
10 




1896 


Males . . . 
Females . . 




189 
246 


112 
113 


42 

66 


10 

34 


13 

18 


6 
5 


183 
236 


6 

10 




1897 


Males . . 
Females . . 




132 
176 


73 

87 


26 
52 


17 

12 


13 

14 


1 
5 


130 

170 


2 
1 




1898 


Males . . 
Females . 




198 
243 


105 
116 


62 

70 


18 
24 


3 

20 


7 
• 7 


195 
237 


3 
6 




1899 


Males . . . 
Females . . 




158 
191 


74 
99 


58 

40 


13 
30 


11 
10 


1 
6 


157 

185 


1 
6 




1900 


Males . . . 
Females . . 




143 
173 


69 

78 


38 
45 


23 

21 


3 
15 


6 
5 


139 
164 


4 
9 




1901 


Males . . 
Females . . 




65 
93 


31 
43 


22 
29 


7 
8 


3 

7 


1 
4 


64 
91 


1 
1 


1 



(486) 



PERT SSIS. j^7 

A disease whose death-rate, in children under 5 years of age, ranks 

fourth, certainly requires attention. In delicate children it is one of the 
most serious diseases we can encounter. 

It is one of the most frequent diseases of childhood and is both infec- 
tious and contagious. It is divided into three stagesi-r- 

First Stage. — The catarrhal stage in which the symptoms of an ordi- 
nary bronchitis appear. 

& cond Stage. — The paroxysmal stage in which the characteristic whoop 
appears. 

Third Singe. — The stage of decline after the spasms have spent their 
force. 

Bacteriology. — Behla found a micro-organism which he believes be- 
longed to the protozoa group. Similar results were obtained by Deichler 
and Kurloff. In 188 T Affanasjew found a bacillus which he called the 
bacillus tussis convulsiva. This germ has been isolated from the expectora- 
tion found in the larynx and trachea. 

Czaplewski and Hensel have found a facultative anaerobic bacillus re- 
sembling, morphologically, the influenza bacillus, but somewhat larger. It 
has been impossible to make a pure culture of this so-called specific micro- 
organism and reproduce the disease in animals. 

Pathology. — We find an intense congestion in the lungs, heart, kidneys, 
and meninges. The immediate cause of the paroxysms of whooping-cough 
must be attributed to a nervous origin. It has been found, experimentally, 
that an irritation of the superior laryngeal nerve will provoke a spasmodic 
cough similar to whooping-cough. When this disease exists a long time' 
there is a profound toxa?mia, which is similar to that form of poison so 
commonly met with in severe infection resembling diphtheria. 

Symptoms. — After an exposure to whooping-cough symptoms may ap- 
pear as early as three days, though sometimes not until one or two weeks 
after such exposure. 

During the first stage the diagnosis is at times very difficult. If one 
or more cases exist in the immediate surroundings, and an exposure to 
whooping-cough is brought out by the clinical history, then it is likely we 
are dealing with whooping-cough. 

The catarrhal stage lasts about one week: not more than ten days. 
Besides the symptoms of bronchitis above mentioned, we have a history of 
the child coughing more at night than by day, and less in the open air than 
when brought into the house. The usual cough remedies will not check this 
cough. The child will not relish its food. There is a craving for liquids, 
although all food seems to irritate and excite the cough. 

Associated with this loss of appetite, there is usually a looseness of the 
bowels and diarrhoea, which particularly affects the colon and produces a 
mucous stool. 



488 THE INFECTIOUS DISEASES. 

The Paroxysmal or Whooping Stage. — The whoop or paroxysm is usu- 
ally heard in the second or third week after the infection has taken place. 
The paroxysm commences with a severe cough, followed by a long inspira- 
tion which has the distinct whoop. The face assumes a reddish or cyanotic 
appearance during this coughing paroxysm. The coughing spasm usually 
ends in vomiting. 

When the paroxysms are very violent severe nose bleeding or haemor- 
rhage may follow a paroxysm. Sudden death has followed paroxysms, evi- 
dently due to cerebral haemorrhage. 

I have frequently had the number of paroxysms counted in twenty- 
four hours, and twenty to fifty are not unusual in a severe form of per- 
tussis. 

The face has a characteristic puffy appearance when the paroxysms are 
well established. The skin will frequently show an intense capillary con- 
gestion, which can most frequently be seen by an inspection of the con- 
junctival mucous membrane. 

Here we will find an engorgement of the smaller blood-vessels distinctly 
evident. The paroxysmal stage lasts from four to ten weeks, although the 
writer has seen cases in which the whoop remained six months, and even 
longer. 

After the disappearance of the whoop the catarrhal stage appears, and 
convalescence is usually established. 

Ulceration of the Frenum of the Tongue. — This seems to be directly 
due to the forcible pushing forward of the tongue during the paroxysm of 
cough. This stretches the frenum and brings it in contact with the teeth, 
causing ulceration. 

The Stage of Decline. — The symptoms of the third stage or stage of 
decline resemble those of the first stage. Catarrhal symptoms continue. 
There is extreme exhaustion from the paroxysms of cough. It renders the 
child very livid. Profound anaemia and heart failure are most frequently 
met with in this stage. 

Particular care must be given to the restoration of the normal func- 
tions of the heart and the respiratory tract ; also in toning up the stomach 
and bowels. Cold extremities are met with, showing a poor circulation of 
the blood. 

Diagnosis. — When the blood shows a marked lymphocytosis in a case of 
continuous cough we should suspect pertussis. A high lymphocyte count 
usually means pertussis. 

One attack of whooping-cough usually renders the child immune. 
This is, however, not always the case. Cases are recorded in which whoop- 
ing-cough has appeared a second time. 

Complications. — The most frequent complication seen by me is bron- 
cho-pneumonia. Chronic pulmonary disease, such as tuberculosis, has fre- 



PERTUSSIS. 489 

qucntly followed pertussis. Empyema has been seen by me associated with 
pertussis. The heart must be carefully watched and cardiac stimulants 
given when weakness is noticed. Heart-strain from the paroxysms has 
occasionally caused death. Epistaxis of a very serious nature may result 
from a violent spasm. Cerebral hemorrhage and sudden death due to 
apoplexy has followed violent paroxysms of cough. Prolapse of the rectum 
is a common occurrence when the spasms are prolonged. Hernia may also 
result from severe spasms. I have seen umbilical and inguinal hernia very 
frequently during the spasmodic stage of pertussis. 

The danger of suffocation must not be forgotten and intubation of the 
larynx (see chapter on "Intubation") may be required. 

Convulsions are not frequently met with in the course of this disease. 
The writer met with a case of pertussis in which death resulted from con- 
vulsions after a coughing paroxysm. They are usually fatal when they do 
occur. Paralysis frequently follows severe spasms caused by intracranial 
haemorrhage. Such paralysis usually improves under careful treatment, 
and not infrequently do we find children completely cured after a distinct 
stroke of paralysis. Strabismus occasionally follows this disease. 

Aphasia and loss of vision are sometimes encountered. These condi- 
tions frequently improve when the system is strengthened by restorative 
treatment. 

Bloody urine is frequently met with in very young children during 
the course of a severe attack of pertussis. 

Xephritis is sometimes met with and may last for months after the 
disease has disappeared. Diabetes mellitus has been reported following an 
attack of whooping-cough. The writer has seen a case of this kind, extend- 
ing over two years, which resulted favorably. 

Prognosis and Course. — This depends upon the presence or absence of 
complications. When laryngeal complications such as oedema of the 
glottis exist, the prognosis is grave. If broncho-pneumonia is present and 
the heart is weak, then the prognosis is doubtful. Atelectasis involving 
part of the lobe or even several lobes of the lung is usually met with in 
rickety children, and results fatally. When pleurisy complicates whoop- 
ing-cough, a guarded prognosis should be given. If an effusion exists the 
same should be watched until it is absorbed. If an empyema complicates 
a case of violent pertussis the prognosis is very poor. Emphysema is fre- 
quently met with when there is severe and frequent coughing. When this 
latter complication exists recovery is very slow. 

Treatment. — Prophylactic Treatment: When a case of whooping-cough 
occurs in a house, it is a good plan to give the other healthy children from 
5 to 10 grains of sulpho-carbolate of sodium, three or four times a day for 
two weeks. This will be during the longest period of incubation. Exer- 
cise in the open air, walking, etc. Eresh air at night by proper ventilation, 



490 THE INFECTIOUS DISEASES. 

and dietetic measures may be the means of preventing an attack of per- 
tussis. 

Owing to the contagious character of this disease we must insist on the 
strictest isolation of every child suffering with whooping-cough, until the 
last vestige of cough has disappeared. The specific infectious character of 
this disease demands the strictest attention to the disinfection of every bit 
of clothing worn by such a child. In addition thereto all expectoration or 
vomit must be disinfected by the addition of a 1 to 2000 solution of bichlo- 
ride of mercury. It is only in this manner that we can destroy the infec- 
tious agent which is known to transmit this disease. A child suffering with 
whooping-cough must sleep alone, and if at all possible, should have sepa- 
rate dishes and utensils during the whole course of this disease. 

Feeding. — Next in importance to hygienic measures is feeding. If an 
infant, at the breast has whooping-cough, then it is a simple matter to regu- 
late its food. If spasms of cough are followed by frequent vomiting, then 
the writer insists on feeding the nursing infant soon after the spasm ceased. 
When coughing spasms are provoked to such an extent that no food will be 
retained, and if there is a very feeble pulse, and exhaustion following such 
inanition, then, and then only, must we resort to rectal feeding. This form 
of feeding has been described elsewhere in this book. (Eead chapter on 
"Bectal Feeding.") 

When vomiting is very serious, Baginsky recommends menthol in 
doses of V 10 or 1 / 4 grain, repeated every two hours until the desired effect is 
produced. Frequently the inhalation of chloroform or ether may be neces- 
sary to check the paroxysms and relieve vomiting. 

Hygienic Treatment. — The intelligent management of a case of whoop- 
ing-cough depends on the environment in which the patient exists. Thus 
if a child suffers with severe whooping-cough and lives in a crowded apart- 
ment in the city, it will be immediately benefited by a change to the 
country. Whether such children be given mountain air or removed to the 
seashore is immaterial. The pine-needle air of the woods or mountains is 
certainly beneficial. The same is equally true of the ozone at the seashore, 
or on an ocean trip. Thus one child will be benefited by a trip to Europe, 
while another will receive an equal benefit by being sent to the mountains. 
When, however, neither of these trips are possible, then common sense 
must be used. 

The first remedy demanded is fresh air. It is advisable to insist on 
having the windows open both night and day if the child is indoors, and 
to instruct the mother or nurse regarding the necessity of fresh night air 
as well as fresh day air. 

There seems to be a predilection regarding the danger lurking in night 
air, and children are crowded into stuffy apartments and permitted to 
breathe vitiated air at night rather than open the windows. This is the 



PERTUSSIS. 491 

real cause of such children coughing more at right than during the day. 
The administration of oxygen and also of ozone has its advocates. All 
noxious odors and all irritants, such as tobacco smoke or kitchen vapors, 
must be guarded against; in other words, the air should be kept as pure 
as possible. 

Medicinal Treatment. — We have no specific in the treatment of this 
disease. For the treatment of whooping-cough hundreds of remedies have 
been suggested. Some of the older remedies, such as belladonna, 
hyoscyamus, codeine, and morphine, have their advocates. 

There is no question in my mind about the efficacy of some of the 
remedies just mentioned. In spite of the value of those drugs, a great 
many cases will show no benefit after their use. 

Every pediatrist is guided by his individual experience, and thus it is 
that one remedy will do good in a certain class of cases and disappoint in 
another. 

Bromoform 1 was introduced in this country by the author. 

In a series of 51 cases published at that time, marked improvement was 
the rule in most cases, although there were several instances in which no 
appreciable benefit was observed. 

The dose of bromoform is from 2 to 5 drops three times a day, for a 
child 1 year old. It is wise to begin with a minimum dose and gradually 
increase the same to the point of toleration. We commence with a 2-drop 
dose, give it three times a day, then increase 1 drop more each' day until 
a decided amelioration of the paroxysms is noticed. My plan has been the 
following : To instruct the mother or nurse to count the number of parox- 
ysms that the child has in twenty-four hours. 

IJ Bromoform 1 drachm 

Spir. vini albi 2 Va drachma 

Syr. tolu 1 ounce 

Mucilag. acacia q. s. ad 2 ounces 

M. From Va to 1 teaspoonful every four hours. 

Owing to the extreme volatility of this drug, great care must be exer- 
cised in its administration, and it is a good plan to keep the same in a well- 
stoppered bottle and also in a cool place. 

The increase of the dose of bromoform depends on the point of toler- 
ance. Thus, if the child appears very drowsy and sleepy and shows signs 
of intoxication after a 3 or a 4-drop dose, then it is a good plan to combine 
a small dose of caffeine citrate with it, or if the child is old enough, give it 
a few drops of strong coffee after the dose of bromoform has been given. 

1 The article appeared in extenso in the New York Medical Record for September 
6, 1890. 



492 THE INFECTIOUS DISEASES. 

The writer has frequently given 7, 8, 9, or 10 drops of pure bromoform in 
one dose to an infant 1 year old, by gradually increasing the dose from two 
drops in the manner above described. 

Bromoform acts similarly to chloroform and it is advisable to use 
extreme care with children who might be very susceptible to ordinary drug 
treatment. Children suffering with profound anaemia or rachitic children, 
or children having tuberculosis, or those suffering with syphilis, should be 
carefully watched. 

Toxic effects have been reported both in this country 1 and abroad. 

Antipyrine, in doses of 1 to 5 grains three times a day, acts quite well 
in some cases. It is well worth trying, especially in very nervous children. 

Tussol. — Tussol is a derivative of antipyrine and has been advocated 
by Eehn 2 and later by Eothschild, 3 and in an elaborate paper by Dr. 
Urban, from the Children's Hospital of Vienna. 

The writer has had some experience with tussol and has found instances 
in which the paroxysms were modified just as they were when phenocoll or 
antipyrine was used. The method of administering it was to suspend it 
either in syrup of orange or raspberry syrup, in doses varying from 2 to 5 
grains for a child 1 year old, older children, larger doses in proportion. 

What has been said regarding the depressing effect on the heart by the 
antipyretic group applies equally strong to this latter day drug. When 
large doses are given, then some cardiac stimulant should be combined with 
it to offset the depressing action on the heart. 

Fischal 4 gives a clinical report regarding the newer remedies suggested 
in the treatment of whooping-cough, as lactophenin and euchinin. These 
belong to the antipyretic group. Other substances have been recommended 
in this disease. Among the newer remedies suggested are pasterin, anti- 
tussin, pertussin, antispasmin. 

Antitussin. — A conscientious trial of this drug in the children's service 
of the writer, showed no benefit whatever after its use. Hein advocates the 
use of antitussin. 5 

Fischal has seen the paroxj-smal curve of 21 daily, drop to 7 daily, 
immediately after using antitussin. Several days sufficed to complete a cure. 

Phenocollum hydrochloricum has been before the profession for a 
number of years; Martinez Vargas, in Barcelona, advocates the use of this 
drug, after giving detailed clinical histories in an extensive article. 6 



1 "Bromoform Poisoning, Recovery in a Child," published in detail in the 
Annals of Gynaecology and Pediatry, 1897 (Fischer). 

2 Munch. Med. Wochen., 1894, No. 46. 
•Berlin. Klin. Wochen., 1896, No. 1. 

* Med. Chir. Centralblatt, June 29, 1900. 
■ Berlin. Klin. Wochen., No. 50, 1899. 

• Therapeutischen Wochenschrift, January 5, 1896. 



PERTUSSIS. 493 

Wo found beneficial results in a scries of cases in which a groat many 
other drugs had boon previously used. A child one month old received 
about 10 grains of phenocoll in the course of twenty-four hours. 

The action of phenocoll is reported to be very quick. It passes through 
the system and is excreted in about twenty minutes. 

Kobcrt and Mering found that phenocoll does not alter the character 
of the blood. It reduces the temperature, diminishes the quantity of urea 
and of nitrogen, and also the total solids in the urine. It seems to exert 
its influence on the nervous system, causing a decrease in the convulsive 
character of the cough. 

The slightly bitter taste of this drug can be masked by adding a little 
syrup. It acts not only on the nerve centers, on the cerebellum and spinal 
cord, but also on their peripheral ramifications, producing a slight warmth 
in the head and flushing the face. It determines varying degrees of dilata- 
tion of the pupil, especially when administered in large doses; thus 
mydriasis persists even after all other characteristic symptoms of pheno- 
coll have disappeared. 

The dose is from 5 grains, for a child 1 year old, gradually increased 
to 8 grains, administered in water or syrup three times a day until the effect 
is marked. 

Phenocoll has also been advocated by Vergas and Grigorieff, and by 
PolievkstoS in Petersburg. The writer has had some experience with 
phenocoll, and has found that very mild cases seem to respond to its admin- 
istration in the same manner as antipyrine has given results. Specific action 
and immediate relief in severe paroxysmal attacks was not noted. 

Antispasmodics. — When the paroxysms of whooping-cough are very 
severe, especially at night, causing insomnia, it is very vital to give the 
child some sleep. The antispasmodics, like belladonna, require either the 
addition of bromide of sodium or bromide of potassium. A 5-grain dose 
of bromide of sodium, administered shortly before putting the child to 
bed, will frequently allay irritation and give refreshing sleep. The dose 
may be doubled and 10 grains of bromide of sodium given to a child 1 year 
old, if a 5-grain dose has had no effect. Frequently from 1 to 2 grains of 
chloral hydrate added to a 5-grain dose of bromide of, sodium will act more 
beneficially. 

When drugs are not well borne by the mouth and the slightest amount 
of liquid swallowed will cause an irritation and provoke a paroxysm of 
cough, then it is advisable to feed the child per rectum. We can also ad- 
minister the drugs in the form of suppositories per rectum. It is a good 
plan to increase the dose per rectum; thus if a child receive 5 grains per 
mouth, then 10 grains should be given for a corresponding dose per rectum. 

Regarding Antitoxin. — Whooping-cough is a self -limited disease, and 
one single attack is usually protective against subsequent infection. Thus 



494 THE INFECTIOUS DISEASES. 

it appears that some antitoxin may possibly be generated during convales- 
cence. 

As soon as a specific micro-organism can be cultivated and the disease 
reproduced in lower animals, just as we can to-day isolate the specific 
micro-organism causing diphtheria, then we may hope for an antitoxin. 

Vaccination of the arm with bovine -virus has been advocated by some 
in the treatment of whooping-cough. The writer has never seen any benefit 
from its use. It can do no harm if a child has never been vaccinated. 

Anti-pneumococcic serum has been advocated by many for the treat- 
ment of whooping-cough. Why it should be used I fail to understand and 
cannot conscientiously recommend the use of the same in this disease. 

Creosote or creosote carbonate has teen advocated by some in the treat- 
ment of the paroxysmal cough. It has served the writer very well in con- 
junction with codliver-oil and malt as a restorative, after the paroxysms 
had spent their force, but no specific action could be ascribed to the use of 
creosote carbonate alone or in combination. 

When whooping-cough existed in a tubercular child, then marked 
benefit was noted by the administration of 2 to 5 drops of creosote carbonate 
three times a day, given in milk, soup, or broth, and the dose gradually 
increased until 12 drops, three times a day, was administered. The benefit 
derived in these cases must be attributed to the action of creosote for the 
tuberculosis, rather than its specific action in whooping-cough. 

Steam Inhalations. — Medicated steam is frequently useful, more espe- 
cially when the cough is violent. When pertussis is complicated by bron- 
chitis steam vapor should be used every five or six hours. A teaspoonful of 
beechwood creosote added to a pint of steaming water and placed several 
feet from the child's bed, will impregnate the air in the room. 

Heroin has been extolled by many as a useful adjuvant in the treat- 
ment of catarrhal affections. The following case is interesting to show the 
dangers o"f idiosyncrasies in some children: — 

An infant, eleven months old, very rachitic, poorly nourished, was exposed to 
whooping-cough in a large apartment house. The paroxysms were violent and 
frequently ended with vomiting. The child was greatly exhausted from cough and 
weakened from inanition. Expectorants and antispasmodics excited little or no 
influence over the cough. 

Heroin, Veo grain, was prescribed three times a day for three days. This 
produced a distinct stupor. Such was the condition noted by me when I saw the case 
in consultation with Dr. John H. Wurthman. There wa-s no rigidity of the sterno- 
cleido mastoid nor was opisthotonos present. The patellar reflexes were present. 
The symptoms subsided when the drug was discontinued and cardiac stimulants were 
prescribed. The symptoms were undoubtedly due to heroin poisoning. It is possible 
that we were dealing with a drug idiosyncrasy as the toxic symptoms passed away in 
about twenty-four hours. 

Dionin in pertussis has been recommended by Von Mering in the fol- 
lowing doses: — 



PERTUSSIS. 495 

For a child 1 year old: — 

B Dionin (Merck) '/• grain 

Aqua 3 ounces 

Big.: One drachm every three hours. 

For a child 2 years old: — 

I* Dionin Vi grain 

Aqua 3 ounces 

Sig.: One drachm every three hours. 

For a child 3 years old: — 

B Dionin 7« grain 

Aqua 3 ounces 

Sig.: One drachm every three hours. 

Pertussin 1 has been used by me for several years with remarkably good 
results. I have given a teaspoonful three and four times a day. To older 
children 2 teaspoonfuls three and four times a day, also at night until the 
paroxysms were modified. 

Restorative Treatment. — Malt extract with hypophosphites and cod- 
liver-oil, sweet cream, milk, eggs, and butter form the most valuable part 
of the treatment. 

Produce Sleep at Night. — Xext to exhaustion from violent paroxysms 
of cough, heart strain, and loss of food from vomiting, is loss of sleep. 
Sleep should be produced to aid in restoring normal conditions. Trional in 
1 to 5-grain doses, repeated in two hours, is very useful in some cases. I 
have previously mentioned the good effects of bromides as antispasmodics. 
Paregoric in 10 to 20-drop doses, according to the age and requirement of 
the case, will be found useful in some cases. A large dose (tablespoonful) of 
castor-oil will frequently exert a very soothing effect on the inflamed and 
sensitive mucous membrane. 

Spray. — A 3 per cent, cocaine spray in the throat, used several times a 
day, or a 3 per cent, eucaine spray will frequently give local relief if severe 
paroxysms are followed by vomiting. The writer has frequently given the 
latter spray in conjunction with one of the above-mentioned drugs. 

Ethyl chloride has been used as a spray during violent spasms. It 
produces anaesthesia, thus affording temporary relief. An oil spray, con- 
sisting of albolin or liquid vaseline used with an oil atomizer, lubricates 
the mucous membrane and sometimes affords relief. 

The Is as o- pharynx. — Pieflex irritations such as nasal catarrh and ade- 
noids frequently excite paroxysms of cough, hence they should be removed 
by operation if present. 

1 Sold in drug stores. Made by Taeschner. 



496 THE INFECTIOUS DISEASES. 

A mild antiseptic irrigation of the naso-pharynx will be found advan- 
tageous. 

For this purpose use: — 

U Dobell's sol 1 part 

Aqua 3 parts 

The above can also be used in the form of a steam spray directed 
against the pharynx. 

Seller's tablets are also valuable. One tablet dissolved in a teacup of 
lukewarm water, or: — 

Mechanical Treatment. — The value of an abdominal binder as a sup- 
port in the treatment of whooping-cough is emphasized by Kilmer. 1 

My personal experience has been quite good with this form of support. 
It probably gives the same mechanical relief as does the strapping in pleu- 
risy. 



1 Section on Pediatrics, American Medical Association, 1904. 



CHAPTER IV. 

PNEUMONIA (LOBAR OR CROUPOUS). 

This acute infectious disease is frequently seen in infancy and child- 
hood. It is caused by the invasion of a specific micro-organism, the pneu- 
mococcus, also known as the micrococcus lanceolatus. The disease rarely 
exists longer than from six to nine days. It terminates by crisis. It is a 
self-limited disease. In some cases it may terminate by lysis. 

Etiology. — This disease most frequently exists in children between the 
ages of 5 and 10 years. Baginsky states that among 173 pneumonias 
studied by him, he found the following: — 

6 children less than 1 year old. 
28 children between 1 and 2 years. 
58 children between 2 and 5 years. 
63 children between 5 and 10 years. 
18 children between 10 and 14 years. 

We find on studying the above cases that the greatest number of pneu- 
monias are found in children between the ages of 5 and 10 years. Schles- 
inger studied a series of cases of pneumonia and found that 96 cases affected 
the right lung as against 66 cases affecting the left lung. He also found on 
the right side of the lung:— 

22 cases affecting the upper lobe. 
7 cases affecting the middle lobe. 
32 cases affecting the lower lobe. 

On the left side of the lung : — 

11 cases affecting the upper lobe. 
00 cases affecting the middle lobe. 
47 cases affecting the lower lobe. 

Thus he found that the lower lobes on both sides of the lungs were 
more frequently affected than the upper lobes, and that the seat of pneu- 
monia in children corresponded with the investigations of Yon Dusch, 
showing that the most frequent seat of pneumonia of the lobar variety is 
certainly found at the base of the lower lobe of the left lung. This is an 
important diagnostic point when symptoms point to the development of 
pneumonia. 

Bacteriology. — The disease originates by an invasion of a specific micro- 
organism first described by A. Fraenkel. Other investigators, among 
them Klebs, Ziehl, and C. Friedlander, have found various micro-organisms 
in the lymph channels, and in the alveoli of pneumonic lungs. Some of 

32 (497) 



498 



THE INFECTIOUS DISEASES. 



these germs have been encapsulated. It remained, however, for Fraenkel to 
find the specific germ causing this disease. Weichselbaum was one of the 
first to prove the positive specific infection of the Fraenkel diplococcus. 




Fig. 151. — Focal Metastatic Hematogenous Streptococcus Pneumonia 
Following Angina, (a) Pneumonic focus with streptococci (blue) inflamed 
surrounding tissue. X 80. ( Ziegler. ) 




Fig. 152. — Croupous Pneumonia. Red hepatization of the lung (alco- 
hol, carmine, fibrin-stain), (a) Infiltrated alveolar septa; (6) fibrinous 
exudate; (c) red blood-cells. X 200. (Ziegler.) 






WANDERING PNEI MONIA. L99 

This diplococcus is found not only in the lungs, but frequently also in the 
meninges, in the nasal secretions from the nasal mucous membrane, and at 
times in the kidneys. Wherever this micro-organism is found there is 
usually an inflammatory condition resulting therefrom. 

When this specific germ was injected into animals, pneumonia always 
resulted. 

Pathology. — There are four stages which have an important bearing 
on the progress and on the outcome of this disease. First, the stage of 
congestion; second, the stage of red hepatization; third, the stage of gray 
hepatization, and fourth, the stage of defervescence or resolution. 

Varieties of Pneumonia. 

Abortive Pneumonia. — This form of pneumonia is frequently disbe- 
lieved by some clinical observers. At times children who are in apparent 
good health will suddenly have intense fever, cough, and on physical ex- 
amination show distinct symptoms of pneumonia. Frequently dullness on 
percussion in addition to bronchial breathing will be plainly made out. In 
two, possibly three days, the whole clinical picture will be changed and the 
child will appear to be normal. This form of pneumonia has been recog- 
nized and studied by other authors, but Baginsky maintains that the dis- 
ease is of the abortive type. It is quite possible that some of these symptoms 
have been latent for several days prior to the detection of the physical signs, 
and thus what appears to be an abortive form of pneumonia covering two 
or three days may easily have existed for several days prior to the detection 
of the same. 

Pneumonia Gastrica. — This form of the disease is one in which the 
Eymptoms of vomiting and diarrhoea predominate, and hence it is known 
as the gastric type of pneumonia. While the lungs will show the usual 
symptoms of a croupous pneumonia, the tongue, stomach, and bowels will 
present symptoms of an intense inflammatory condition of the digestive 
tract. Not infrequently jaundice may be present. 

The conjunctival mucous membrane may be pigmented from the pres- 
ence of bile. The secretions may also show biliary pigmentation. Herpes 
may appear on the upper lip, thus showing that there is an intense inflam- 
matory condition affecting primarily the digestive tract. 

Wandering Pneumonia ("Pneumonia Migrans"). — This form of pneu- 
monia is met with quite frequently. The symptoms are those common to 
lobar pneumonia, as chills, fever, and the usual physical symptoms of a 
consolidated lung in this condition. The name is derived from its tendency 
to spread from lobe to lobe. The infection usually commences in one lobe 
and spreads to the second, to the third, and frequently when the crisis 
has taken place the disease commences with full force in another lobe and 
may continue so for several weeks. That this form of pneumonia is very 



500 



THE INFECTIOUS DISEASES. 




Fig. 153. — Case of Influenza and Pneumonia. The disease spread from 
lobe to lobe so that the child passed through several distinct inflammations. 
This form is known as Pneumonia Migrans (Wandering Type) Careful 
dieting aided by stimulation, and the fever treated by cold compresses and 
cold colon flushings aided recovery. (Original.) 



PLEURO-PNEUMOMIA. 



501 



Berious can be easily imagined. A child having suffered with acute lobar 
pneumonia and passed its crisis with an already weakened heart, and has 
again fco pass through the second, pneumonia and frequently through a third 
and a fourth, must certainly have great vitality in order to recover from 
the depression caused thereby. 

The depressing effect on the heart from a continued fever in addition 
to the toxaemia must be taken into account in giving the prognosis; hence 
it is sale to assume that the prognosis in every pneumonia migrans is neces- 
sarilv grave. Stimulation, which is so urgently called for in. the usual form 
of lobar pneumonia, is imperative in this variety of the disease. 

Pleuro-pneumonia. — It is rare 
to find lobar pneumonia without an 
associated inflammation of the pul- 
monary pleura. Xot infrequently 
with a severe type of broncho-pneu- 
monia covering large areas of con- 
solidation there is a co-existing in- 
flammation of the pleura. It is 
difficult to state at times which lesion 
began first, whether it was the pleu- 
risy or the pneumonia, in a given 
ease of pleuro-pneumonia. 

Patholpgy and Bacteriology.— 
The infection is usually caused by 
the pneumococcus. In pleuro-pneu- 
monia both the visceral and the parietal pleura are coated with a large layer 
of yellowish-green fibrin, in thick, shaggy masses, by which the lung is 
adherent to the chest-wall, the diaphragm, and the pericardium. The 
exudation varies between one-eighth and one-half inch in thickness. It can 
often be stripped from the lung or scraped from the chest-wall by the hand- 
ful. In its meshes small pockets may form which contain only a few drops, 
or sometimes a drachm of pus, or, less frequently, serum. This is the con- 
dition in which the lung is usually found when death has occurred at the 
height of the disease. If the process has lasted longer, larger collections of 
pus may be present. The lung itself shows the usual changes of pneumonia, 
and if there has been any considerable accumulation of fluid, there are in 
addition the evidences of compression. 

With pleuro-pneumonia of the left side, the pericardium is occasionally 
involved. This was seen in two of my cases, the lesions closely resembling 
those of the pleura. In two cases there was also meningitis, and in one 
peritonitis, the exudation in all cases having the same characteristics (Holt). 

Symptoms. — The friction sound is the characteristic feature throughout. 
In addition to the pleuritic friction sounds, the symptoms of pneumonia, 



Day 1 A 3 4 


5 t» 7 


Fafcr. M E MEMEME 


:mememc 


indf 




A 2 -k n 




103 o *JLiM 


\ * 


v V H V 


- tTEt I 


ino° * * - 


-^-OT ! 


102 


Bu^ + 




--t vt 


101 


£ 


ioo°- — -ni"- 


y 

-T--., ; _j 



Fig. 154. — Fever Curve in Pleuro- 
pneumonia. (Original.) 



502 THE INFECTIOUS DISEASES. 

such as bronchial breathing and bronchophony, are found. There is marked 
dullness and frequently flatness on percussion. This condition is sometimes 
misleading. Not infrequently the signs of distant breathing and flatness 
on percussion, in addition to a continuous high temperature will simulate an 
empyema. An exploratory needle introduced may strike a small pocket of 
pus and thus an empyema may be suspected. These cases, if operated, fre- 
quently show nothing but the ordinary signs of adhesions so common at this 
stage of the disease. 

Prognosis. — The prognosis depends on the severity of the disease. The 
prognosis is always worse than in pneumonia, because of an extent of the 
inflammatory process and because many of these cases terminate in tuber- 
culosis. Cases terminating in empyema, if operated, get well. 

Treatment. — The treatment of a pleuro-pneumonia is identical with 
that of an ordinary pneumonia. The fever treatment consists in packing 
the thorax. Cough and pain require codeine or Dover's poAvder. If the 
pain is very severe, strapping the chest with strips of adhesive plaster will 
support the ribs and relieve the strain of the cough. Fresh air, milk, yolk 
of egg, soups, for thirst : orange juice, weak tea, and water, liberally, are 
required. Attention to the bowels and kidneys is an important factor in 
this disease. 

Cerebral Pneumonia. — This type of the disease is one which is very 
frequently met with in which the symptoms of pneumonia are chiefly com- 
plicated by meningeal symptoms; thus clonic spasms or convulsions are 
usually present. In addition thereto there is vomiting, constipation, head- 
ache, opisthotonos, delirium, stupor, irregularity of the jmlse, and, later 
on in the disease, coma. In some cases paralysis is liable to occur. 

Two Instructive Cases of Cerebral Pneumonia.! 

Case I. — Baby E., about six months old, a nursing baby, was seen by me in 
January, 1902, in consultation with Dr. Osias. The history was as follows: The 
child had been ill for several days, was restless and feverish, and had vomited. The 
stools were greenish and contained a large quantity of cheesy curds, in addition to 
mucus. The abdomen was slightly retracted, the extremities were cold; there was 
no oedema present. The child did not seem to take the breast very well and 
vomited frequently after nursing. The temperature was 102 4 / 5 ° F., per rectum, 
pulse 140, respiration 44. Unilateral spasms with twitchings of the muscles of the 
shoulder, arm, leg, and foot were constantly present. Twitchings of the muscles 
of the eye and a constant rolling of the eyeball were noticed; the head was thrown 
backward; the muscles of the neck were rather rigid, although there was no distinct 
opisthotonos. The spasms were confined to the right side of the body; the knee- 
jerk at the patella was absent on the right side; the plantar reflex on the right side 
was slightly present; the patellar reflex was normal on the left side and the plantar 
reflex was more distinct; the pupils responded very sluggishly and were unusually 
large; this dilatation of the pupils persisted through the whole illness, until con- 
valescence w as established. The examination of the thorax showed intense pul- 

i Reprinted from Archives of Pediatrics, February, 1903. 



< KREBRAL PNEI .MOMA. 



503 



monary congestion; there was slight resistance on percussion and marked dullness. 
Judging from the ratio between the pulse and. the respiration, the diagnosis of 
pneumonia was hardly possible. The physical signs on ausculation showed bronchial 
breathing and a distinct crepitant rale. The diagnosis of cerebral pneumonia was 
made, although meningitis per se was excluded. 

The treatment was directed to relieve the pneumonic infection. Expectorants, 
in addition to inhalations of steam, were ordered, (old compresses were used 
as antipyretics, and castor-oil or calomel was given to cleanse the gastro-intestinal 
'tract. The* disease progressed; the temperature increased and rose to 103 Vs F. 



DATE 


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Fig. 155. — A Case of Cerebral Pneumonia. (Original.) 



on the following day, and to 104 -,'-° F. on the third and fourth days. With the 
rise of temperature the pulse-rate was increased to 140°, respirations to 52. (hi 
the fifth day of the disease there was a marked somnolence, stupor and partial 
coma. The head now showed a distinct opisthotonos; the sterno-cleido mastoids 
were very rigid; the pupils were both dilated and the convulsions continued as 
before. Leeches were applied over the mastoid portion of the temporal bone to 
relieve the cerebral congestion; the scalp was shaved and iodoform collodion, 
10 per cent., was painted on the occiput; ice-bags were applied over the whole of 
the cranium as well as to the nape of the neck, mustard foot-baths were frequently 
given and afforded some relief during the severe spasms. An enema consisting of 
chloral hydrate and sodium bromide, 5 grains each, with 1 ounce of starch water, 
was ordered. This was to be repeated every three hours until the spasms ceased. 
Before injecting the above drugs both the rectum and the colon were flushed with 
soap- water enema. 

On the seventh day of the disease there was a distinct crisis, inasmuch as the 



504 



THE INFECTIOUS DISEASES. 



temperature dropped from 104° to 97°, a drop of 7 degrees. (Fig. 154.) Stimula- 
ting expectorants were then ordered in the following manner: — 

IJ Amnion, carb 15 grains 

Syrup, pruni virgin 4 drachms 

Aquae camph q. s. ad 2 ounces 

M. Half a teaspoonful every two hours. 

The child's convalescence continued. The pneumonia completely subsided; reso- 
lution set in; the spasms, which had been so disagreeable and persistent, also stopped. 
The child commenced to show signs of consciousness, played, laughed, and cooed: the 
stools, which had been so greenish and curded, assumed a more natural yellowish 



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Fig. 156. — Cerebral Pneumonia with Higli Temperature and Marked 
Decrease in Temperature After Cold Baths. (Original.) 

color and pasty consistency. The appetite seemed to return; the infant nursed 
better, the nights were more comfortable, and the child slept from one feeding time 
until the next. 

Case. II. — Hannah T., 7 years old, was taken sick with fever, complained of 
being tired, and was very thirsty. She had anorexia and was inclined to constipation. 
She also complained of headaches. When first seen by me her temperature was 
103.4° F. in the mouth, the pulse 168, respiration 34. She had a very coated tongue; 
the throat was dry. there were no patches visible. There was no history of exposure 
to contagious diseases; a gastric catarrh was suspected. The respiration and pulse 
ratio suggested a pulmonary complication. 

The physical examination of the thorax gave no evidence of consolidation, 
merely roughened, harsh breathing, some rhonchi and slight resistance of percussing 
the right apex anteriorly. Xo diagnosis except "fever" was made. I ordered 
calomel 1 grain with powdered rhubarb 3 grains. Citrate of magnesia was given 
for the thirst. A fluid diet, consisting of equal parts of Seltzer and milk, with 
sponging of the chest with alcohol and water every hour, and cool cloths, moistened 



CEREBRAL PNEUMONIA. 505 

with evaporating lotions like bay rum or Florida water, to the forehead were also 
ordered. 

I examined a specimen of urine which contained nothing abnormal. On the 
following morning, twelve hours after my first visit, the temperature by rectum 
was 104.4° F., pulse 172, respiration 68 while asleep. The bowels had been 
thoroughly cleaned, still there was no evidence of pneumonia, but the child seemed 
to be greatly depressed. There was marked apathy; the child was very restless and 
had not slept. Constant twitchings of the muscles of the face and extremities 
occurred; the child cried out while in the stupor, refused food, attempted to bite 
and screamed loudly. The patellar reflexes were both present, the pupils reacted 
normally, the head was not retracted nor were the muscles rigid. There was no 
opisthotonos; the child could be roused by loud talking, or by being touched. 
The temperature in the evening was 106.2° F. by rectum, the pulse 124, respiration 
40. One drop doses of tincture of aconite were given every hour for eight hours 
and had no effect on the temperature, but did seem to reduce the pulse-rate and 
steady the heart's action. 

The cold pack was ordered, to be renewed every half-hour until the temperature 
dropped to 102° F. Freshly prepared spiritus mindererus, one-half teaspoonful every 
half-hour until the temperature remained at 102° F., was also ordered. Warm 
mustard foot-baths were ordered to stimulate the circulation, and whisky with milk 
(3j to 3iv), whenever possible. No distinct evidences of pneumonia were obtained on 
auscultation or percussion. 

The temperature continued to rise, until 106° F. was reached. Dry cups were 
applied over the posterior portion of the lungs, also an ice-cap to the head. Colon 
flushings with water at a temperature of 60° F. were also ordered, to be 
repeated every three hours. These seemed to have a very soothing effect on the 
nervous system. The child was much quieter after them and the temperature was 
gradually reduced. 

Frequently after a cool tub bath, combined with a cold pack, the temperature 
dropped three to four degrees. (Fig. 156.) Creosote carbonate, in 3-drop doses, 
was ordered every three hours, to be given in milk, soup or chocolate. This dose 
was increased gradually by the addition of one drop each day, until the child 
received ten drops every four hours. No systemic disturbance was noticed, there 
was no discoloration of the urine and no toxic symptoms resulted from the creosote 
treatment. A decided antithermic effect without cardiac depression was noticed. 
(A convenient way of giving the creosote is to add the drops to some Tokay wine 
or to combine it with whisky and water.) 

Creosote steam inhalations were also ordered. Beechwood creosote, about a 
teaspoonful to a pint of boiling water, was permitted to steam on a table several 
feet from the patient. This powerful vapor soon impregnated the air so that the 
creosote could be smelt throughout the whole apartment. It certainly acted very 
well, not only on the temperature but also in loosening viscid secretion. 

The vital point in the treatment consisted in giving a supporting diet of eggs 
beaten up with sugar and Tokay wine, concentrated soups, and milk pre-digested with 
peptonizing powder. Malt extract was given as a restorative and also for its 
diastasic effect. The treatment was continued until the child's temperature remained 
normal for several days, when all forms of creosote were discontinued. 

It is interesting to note that very great depression of the nervous system, 
violent twitchings of the muscles and talking aloud while asleep, continued for 
several weeks after convalescence was established. The child slept at least twenty 
hours out of the twenty-four for fully one week. It was at times difficult to arouse 
her to take nourishment. This great stupor was evidently due to the profound 



506 THE INFECTIOUS DISEASES. 

toxaemia which existed. The urine, which was frequently examined, showed an 
excess of phosphates, gave a strong diazo reaction, contained neither albumin nor 
sugar. The child was discharged after eight weeks and is in good health to-day. 

The following symptoms were the most noteworthy in the cases reported: — 
(a) Unilateral spasms, twitchings of the muscles of the shoulder and the 
arm, and of the leg and foot, were constantly present. (5) Twitchings of the 
muscles of the eye and a constant rolling of the eyeball, (c) The head was thrown 
backward. {d) The patellar reflex was absent on the affected side. (e) The 
plantar reflex was slight on the affected side, (f) Distinct evidences of pneumonia, 
bronchial breathing and marked dullness on percussion. (g) Convulsions and 
marked stupor later in the disease. (7i) When the crisis appeared in the pneumonia, 
the cerebral symptoms subsided. {i) Marked nervous depression and extreme 
hyperesthesia of the body, which continued for weeks after all inflammatory symp- 
toms had subsided. 

Sclilesinger, in studying this disease, noted that it existed chiefly in 
children between the third and sixth years. 

In acute apical pneumonia we usually note cerebral symptoms due to 
the irritation of the cervical ganglion. These s}anptoms subside with the 
crisis of pneumonia. They must not be confounded with meningitis, which 
is a distinct disease, although a frequent complication of pneumonia. 

Symptoms and Course. — The disease is usually ushered in with con- 
vulsions. At times vomiting and diarrhoea may be the first, symptoms 
noticed. Chills are very rarely seen in children. The cheeks are usually 
very red and show the characteristic flush so well known in adult pneu- 
monia. The respirations are increased, the pulse is accelerated, and the 
temperature rises. One of the most important diagnostic points and one 
upon which I lay great stress is the "ratio between the pulse and respira- 
tion." Normally the ratio is 1 to 4, and when this ratio is increased, as, 
for example, "when there are 60 respirations and 140 pulse beats, then the 
ratio of 1 to 4, which normally existed, is certainly disturbed. By this 
disturbed ratio alone we can frequently make a diagnosis by the process of 
exclusion. Especially is this true in those cases of "central .pneumonia" in 
which the disease develops in the center of the lung and gradually spreads 
toward the periphery. When such central pneumonia exists, the physical 
signs will be so masked that bronchial breathing will be hardly discern- 
ible. The temperature will suddenly rise to 102°, 103°, and frequently 
to 105° F. The temperature in rachitic children will sometimes rise 
to 106° and 107° F. It is this class of cases that show the most severe 
form of depression from irritation of the thermic centers. In these rachitic 
children we usually note that the invasion of pneumonia begins with a con- 
vulsion or a series of convulsions. 

Children old enough will frequently complain of abdominal pains. 
Thus we must not be misled by gastric or gastro-intestinal symptoms until 
we can exclude the lungs as the seat of the disease. The physical sign most 
commonly associated with this disease is dullness on percussion over the 



CEREBRAL PNEUMONIA. 507 

affected area of the lung. In addition thereto there will be bronchial breath- 
ing. If the child cry, a loud bronchophony will be heard. There will also 
be an increased vocal fremitus. These symptoms usually remain the same 
for a few days, although they may increase in intensity. 

Between the sixth and the ninth day, rarely earlier and very rarely 
later, a crisis takes place in which the temperature will suddenly drop to 
normal. The patient will be covered with a profuse perspiration; the 
pulse, which formerly was full, bounding and accelerated, will be found 
smaller and less frequent. The former flush which existed will give place 
to a distinct pallor of the skin, and the observing physician will note a 
decided change in the patient. This condition, known as the crisis, may 
come on suddenly or gradually. In some cases the fever drops slowly — 
i.e., by lysis, until normal is reached. 

Pulse. — The pulse-rate is one which is a very important factor in con- 
nection with this disease. While it may be 120 and be quite regular in 
action, it is not uncommon to find the pulse-rate 140, and even 160. The 
frequency of the pulse is not as important a factor in determining the 
progress of this disease as is the character of the pulse. Thus, to illus- 
trate, if a pulse is not frequent, but is weak and arythmic, such a patient 
should be regarded as in imminent danger and requires very frequent and 
careful stimulation. A condition of collapse may be looked for in such a 
patient, and treatment directed to the prevention of the same is indicated. 
If the pulse-rate has been 120, and it suddenly increases to 140 or more, 
then some complication must be suspected and the child carefully exam- 
ined to determine the cause of this sudden increase of the pulse-rate. 

Respiration. — The whole respiratory condition is superficial and seems 
to call the accessory respiratory muscles into play. When the respiration 
is above 40 per minute, the diagnosis is usually very positive. 

Lack of Expansion. — A lack of expansion may also be noticed. It 
involves the whole of the affected side and is not limited to the sub- 
clavicular region. In pneumonia this lack of expansion in the subclavicular 
region is marked, even though the inflammatory process is situated at the 
base. It can be observed as early as the first day, and lasts throughout the 
entire course of the disease. This early appearance of the sign is of especial 
importance, since the physical signs of involvement of the lung are so 
frequently delayed in cases of infantile pneumonia. 

The sign is best elicited in the dorsal position, and is easily seen on the 
exposed chest in quick respiration. 

One writer says he has recognized by this sign alone pneumonia occur- 
ring in a supposed case of appendicitis, and also has discovered pneumonia 
complicating typhoid and influenza. 

The Temperature. — A rise of temperature usually implies the invasion 
of the specific micro-organism and hence is one of the earliest symptoms 



508 



THE INFECTIOUS DISEASE! 



of this disease. It usually rises from 102 
the crisis. There is. however, a morning 



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Fig. 157. — Lobar Pneumonia of a Severe 
Type, seen by me in consultation with Dr. S. 
M. Landsmann. The effect of the poison is 
easily seen by studying the pulse-rate. Case 
Recovered. Original.) 

i See "Blood in Pneumonia,*' page 728. 



t 105° F.. and remains so imtil 
remission : thus, we find the tem- 
perature about one degree lower 
in the morning than we do in 
the evening. In pneumonia 
we frequently find a condition 
known as the *"proerisis." This 
procritical stage exists one day 
before the crisis, as a rule. 
The temperature will suddenly 
fall to normal on the day pre- 
ceding the crisis. It has a valu- 
able prognostic significance, 
showing that the inflammatory 
stage has now terminated. 

The Blood in. Pneumonia. 1 
— Baginsky maintains that the 
examination of the blood will 
show the progress of this dis- 
ease, and he believes that the 
leukocytosis so common in this 
disease has an important bear- 
ing on the prognosis of this 
condition. Felsenthal and 
Schlesinger. also Monti. Berg- 
grun. and Loos, have found 
that there is an increase of 
the polvnuclear cells, whereas 
the eosinophile cells disappear. 
When the temperature returns 
to normal during the crisis in 
pneumonia, the leucocytosis 
which formerly existed also 
disappears. Thus some au- 
thors speak of a f "blood crisis." 
The Urine. — This is fre- 
quently high-colored and very 
scanty, especially so during 
the height of the disease. It 
also has a very high specific- 
gravity and frequently con- 
tains albumin. Acetone can 
also frequently be found in 



CEREBRAL PNEUMONIA. 509 

the urine. The albumin frequently disappears after the erisis. The 
phosphates seem increased, though some authors maintain that they are 
decreased during the progress of this inflammatory type of disease. The 
diazo reaction is only found in that form of pneumonia which seems to 
have a typhoid tendency. Indican is very rarely or never found unlesd 
there is some form of intestinal putrefactive complication. 

Relapse. — It is not infrequent to have one and the same area of lung 
reinvaded; thus the disease may run a second course over the same portion 
of the lung just as it did in the first attack. 

Diagnosis. — The diagnosis of pneumonia is easy when the physical 
symptoms of dullness on percussion, bronchial breathing, moist rales, and 
bronchophony are shown. These symptoms are not always present and are 
frequently absent during the first few days of the disease. The diagnosis 
can be made by the disturbed ratio between pulse and respiration, as pre- 
viously noted. In addition thereto, the peculiar character of the respira- 
tion, added to the cough, will certainly aid in establishing the diagnosis. 
The vital point to remember is that normally, bronchial breathing is heard 
posteriorly between the scapulae and also in the regio supraspinata dextra. 
We must also remember that dullness on percussion appears somewhat 
higher on the right side posteriorly in the lower lobe than on the left side. 
The positive diagnosis can therefore only be made by noting the physical 
signs in the lungs and excluding the symptoms pointing to a gastric catarrh, 
to a typhoid fever or a meningitis. 

Atelectasis pulmonum can easily be differentiated from pneumonia by 
the absence of fever and by the marked difference in the dullness on per- 
cussion and usually by the absence of bronchial breathing. When fever 
recurs after it has apparently terminated, some complication must be sus- 
pected. Symptoms pointing to a pleuritic effusion are, dullness on percus- 
sion and diminished respiratory murmur over the affected area. Gangrene 
of the lungs can usually be detected by the odor of the breath and the asso- 
ciated condition of collapse. If the condition assumes a chronic type and 
is associated with headache and fever, and if the child, in addition, com- 
mences to emaciate, then we may suspect the development of tuberculosis. 
To render such diagnosis positive, some of the sputum or expectoration 
should be examined for the presence of tubercle bacilli, the presence of 
which will establish the diagnosis. The absence of tubercle bacilli in the 
sputum does not necessarily mean that tuberculosis is absent. 

The Prognosis. — The prognosis of croupous pneumonia is relatively 
good. Out of 173 cases reported by Baginsky, of Berlin, 4 per cent. died. 
These latter children were very poorly nourished. 

Fatal cases may be expected in bottle-fed infants rather than in breast- 
fed infants. An abnormally developed thorax so common in rickets, has an 
important bearing on the prognosis of this disease. Pigeon-breasted and 



510 THE INFECTIOUS DISEASES. 

narrow-chested infants having an improperly developed lung space, are more 
prone- to a fatal termination. 

The development of symptoms of tuberculosis or abscess of the lung 
or the extension of a pneumonia and the continuation of the same, will mean 
a depression of the heart's action and an inhibiting of the recuperative 
tendency. The vital point will be the question of nutrition. The greater 
the amount of food taken the better will be the chance for the patient's 
recovery; thus the maxim in treating a pneumonia, "Feed the stomach," 
is one that I have learned to indorse and verify. 

Treatment. — The most important symptoms to be remembered in the 
treatment of this disease are the condition of the heart, the pulse-rate, the 
respirations, the temperature, and the condition of the kidneys, to be noted 
by the quantity and the quality of the urine secreted. 

Isolate the Child. — As lobar pneumonia is an acute infectious disease 
caused by the invasion of the pneumococcus, it is transmittible. Our first 
duty is to isolate. A case of pneumonia should be isolated as strictly as a 
case of diphtheria. All healthy persons should be excluded, be they friends 
or family. It is best to let them know that this disease can be disseminated. 

In the treatment of pneumonia we must remember that toxaemia and 
high temperature will produce degeneration of the muscular fiber of the 
heart, which, if prolonged, will result in heart failure. Hence our treat- 
ment must be directed to lowering the temperature and to control the 
inflammatory process before stagnation of the blood and hepatization have 
taken place, thus aiming to retain the integrity of the respiratory tract. 

Any interference with the proper action of the respiratory apparatus 
leads to overloading and ultimate failure of the right side of the heart. 
Hence we must seek to keep up the respiratory pump by lessening the fre- 
quency and increasing the depth of the respirations. 

A great many cases will get well without treatment. This is called the 
"self-limited" condition. The disease simply runs its course, and if the 
patient is properly fed, strengthened, and guarded, a favorable termination 
may be expected. On the other hand there are certain symptoms which 
demand treatment. For example, hyperpyrexia will require treatment, espe- 
cially so, as the continuation of the same may be the means of developing 
disturbances resulting in convulsions. My preference has always been for 
the use of cold externally. If cyanosis exists then warm flaxseed poultices 
may be tried. 

The sudden application of cold externally causes a deep inspiration and 
consequent forcing of air through the alveoli, thus preventing atelectasis. 
The air surrounding the child should be kept moist with steam from a tea- 
kettle, having a long spout directed toward the child (Fig. 137). 

The following case was attended by me in the babies' ward of the New 
York Post-Graduate Hospital: — 



CEREBRAL PNEUMONIA. 511 

Child F. A., 5 years old. My attention was called on August 12th to a tem- 
perature of 99V»° F., which rose to 104 8 /i° F., by 8.30 the following evening. Per- 
cussion showed dullness over a complete lobe of the left lung, bronchial breathing, 
cough, no expectoration. The respiration rose from 36 in the morning to 50 
in the evening, and the pulse from 120 to 130 per minute. Until the diagnosis 
was positive the child was put on the expectant plan of treatment. The 
temperature rose to 105° F. on the second day, in spite of sponge baths con- 
sisting of equal parts of alcohol and water. After a few hours the temperature 
increased to its former height, sometimes going beyond that, prior to the sponge 
bath. 

In order then to have a more lasting effect, it was deemed necessary to give 
the tub baths, that is, to immerse the child from the neck to the feet in water of 
about 90° F. and then adding ice until the temperature of the bath is 70° F. The 
child was kept in the bath from two to five minutes. 

The first tub bath brought the temperature from 104 »/»* F. to 100° F. This 
drop lasted about two hours. The temperature did not rise more than two degrees 
until the following afternoon at 4 p.m., when it reached 104 */ s ° F. This is a natural 
course in a severe pneumonia. The second tub bath had the effect of lowering the 
temperature from 104 */ B ° F. to 101 1 / s ° F., a decrease of 3 */»* F. in one hour. 

On the 19th of August, the eighth day of the disease, the temperature reached 
104 8 / 5 ° F. at 6 p.m. A tub bath given brought the temperature to 103° F. at 7 P.M., 
a fall of 1 8 / 8 F. in one hour. This same temperature continued until 9 p.m., after 
which it began to fall, reaching normal on the following day, the ninth day of 
disease. The boy was discharged cured. He was entirely well when I last heard of 
him. 

In the above case, true symptomatic treatment was carried out. The severe 
cough received an expectorant with an anodyne (codeine) when necessary to relieve 
pain. Bowels and bladder were carefully watched. Stimulants given when required 
— no antipyretics. Diluted milk and whey, every three hours. Cool water when- 
ever thirsty. 

Drug Treatment. — When high fever persists in a weakened child with 
very low resisting power, such fever must be reduced. The child's system 
must be carefully watched while fever is in progress. One child will tole- 
rate a temperature of 105° F., laugh and play, and take its food regularly, 
while another child in a similar pulmonary condition will show extensive 
cerebral irritation, somnolence, tremor, twitching of the muscles, and pos- 
sibly convulsions at a temperature of 103° or 104° F. In the latter instance 
it shows that the poison from the pneumococcus infection has overwhelmed 
the nerve centers governing heat production, and in such instances when 
decided nervous or cerebral symptoms present themselves, "a reduction of 
temperature is demanded," or we must not be surprised to see convulsions 
set in, with probably a fatal termination. 

How Shall We Reduce the Temperature in Children? — When we con- 
sider that antipyretic drugs depress the nerve centers governing heat pro- 
duction and increase the work of the emunctories, already loaded down by 
poison brought to them for elimination, it can be seen that their use is 
contraindicated. Those who believe in phagocytosis may be reminded that 



512 THE INFECTIOUS DISEASES. 

antipyretics arrest the development of leucocytosis, and thus remove one of 
the means of destroying the germs of the disease according to one theory, 
or the antitoxin generated or developed according to another (Hobart A. 
Hare). 

Jacubowitsch and Muller and many others have proved conclusively 
that antipyrine decreases the elimination of urea by the urine. It also 
decreases the urinary flow, which is a very harmful effect, when we con- 
sider the great importance of eliminating effete matter from the body. 
That antipyretics depress the heart's action is only too well known, there- 
fore, rather than to combine them with musk, camphor, or other cardiac 
stimulants, I have discarded them. 

When drugs are used as antipyretics the coal-tar products are usually 
the ones suggested. Lactophenin, antipyrine, phenacetin, salol, sali- 
pyrine, and quinine are among the more common antipyretic measures 
used. The tincture of aconite, in 1-minim doses, repeated every hour, 
has a remarkably good effect on this disease. In addition thereto, spirits 
of mindereri in half-teaspoonful doses, repeated every hour, will have a 
very good diaphoretic effect. Dover's powder will relieve cough and will 
also aid diaphoresis. 

For difficult breathing nothing will serve as well as local depletion. 
For this purpose the application of dry cups over the affected areas of the 
lung will afford in some instances immediate relief. Dry cupping may 
be repeated in severe dyspnoea in twelve hours if necessary. Tincture of 
iodine applied locally over the area of the lung affected will also be advan- 
tageous in some instances. 

If convulsions persist an ice-bag applied over the head and also at the 
nape of the neck will be very valuable. 

I frequently use one or two leeches applied over the mastoid process 
of the temporal bone and permit very free bleeding. This is especially 
indicated when there is intense engorgement of the brain with marked 
stupor and coma. We can frequently relieve congestion by the application 
of leeches to the alae nasi. A simple but most effective remedy is the use 
of mustard foot-baths frequently given. 

To relieve the cerebral hypersemia, calomel in 1 / 10 -grain doses, and 
increased, may be repeated until liquid stools have been produced. It is 
one of our most valuable remedies and should be used at the onset of a 
suspected pneumonia. Attention to the stomach and bowels will frequently 
be the means of saving the life of the patient. I insist upon a loose con- 
dition of the bowels, and if the same cannot be produced by the admin- 
istration of calomel, then an enema should be given by flushing the colon 
as often as once in twelve hours to cleanse the parts. When children are 
old enough, then one of the most valuable remedies is to give copious drinks 
of citrate of magnesia. This will not only quench the thirst, but will act 
as a laxative, and in addition thereto stimulate the secretion of urine. 






CEREBRAL PNEUMONIA. 513 

We find therefore that the emunctories require especial stimulation and 
attention during the course of lobar pneumonia. 

In no disease is strychnine more valuable than during the course 
of pneumonia. Very small doses of only 1 / 200 or V 100 grain, repeated 
every hour, may be given without fear during the progress of this dis- 
ease. The question of stimulation is one of individuality. Each case 
must be treated on its own merits and the individual condition studied. 
When the heart's action is feeble and the pulse is thready, whisky must 
be given. In some cases five to thirty drops of good whisky may be 
given as often as every half-hour until the pulse responds to the stim- 
ulant. I frequently combine strychnine with whisky. In other cases 
champagne in half-drachm or drachm doses will be found far more 
effectual. Some children object to the taste of whisky or champagne, but 
will take a sweetened wine. In such cases give good, old Tokay in half- 
drachm doses as often as is required. When there is an aversion to the 
taking of medicine or if the child rebel against stimulation by the mouth 
and it is urgently called for, then half a teacupful of hot water, temperature 
of 100° F., to 105° F., to which a teaspoonful of either whisky or alcohol is 
added, may be thrown into the colon by means of a colon tube. Hypo- 
dermic medication must not be overlooked, and frequently it is wise to use 
whisky, ether, or spirits of camphor. A valuable method of giving camphor 
hypodermically is by injecting camphorated oil, from 5 to 15 minims. Musk 
is one of our best cardiac stimulants, and if the pulse-rate is feeble it may 
be given in 1 to 5 -drop doses, repeated in three or four hours, if necessary. 

Hygienic Treatment: Room Temperature. — One of the most impor- 
tant factors is the regulation of the temperature of the room. Every child 
having a pneumonia should be put into a room having a temperature of 65* 
to 70° F. An equable temperature should be maintained, as the same is 
very grateful during the febrile stage of this disease. Fresh air should al- 
ways be admitted. 

Oxygen. — When severe dyspnoea occurs and if cyanosis exists, then 
oxygen inhalations may be required. Under these conditions several res- 
pirations should be given every few minutes until the lips lose their cyanotic 
appearance and again have their natural color. 

Sponge Baths. — The surface of the body should be sponged with tepid 
water every day. Equal parts of alcohol and water are grateful to the 
patient, and should be used every hour if the temperature requires it. If, 
however, the temperature is not high, then a sponge bath to which a little 
alcohol has been added will be grateful, and may be given every morning 
and evening. 

Another valuable means of reducing the temperature is by sponging 
every hour with acetic ether. This must be cautiously used, owing to ita 
volatile and inflammable tendencies. 

ss 



514 THE INFECTIOUS DISEASES. 

The Oil-silk Jacket — This jacket is valuable when we desire a dia- 
phoretic effect. It also prevents the chilling of the surface of the lung by 
maintaining a uniform temperature. The details of making this jacket 
can be found in the article on "Broncho-pneumonia," page 462. 

Dietetic Treatment. — As previously stated, the prognosis in this con- 
dition depends on the amount of food the patient will take. A milk diet 
should be prescribed. Buttermilk, kumyss, zoolak, rice and milk, farina 
and milk, oatmeal and milk, and cold foods, such as cornstarch pudding, 
rice pudding, and tapioca pudding, are very grateful. If the child is very 
thirsty and is over 2 years old, ice cream may be permitted very sparingly. 
This is very grateful to the little patient, and if made from fresh cream is 
very nutritious. Concentrated soups, chicken broth, and veal broth may 
be permitted. So also calf's foot jelly, chicken jelly, albumin in the form 
of raw white of egg, to which some sugar is added, may be given. A soft- 
boiled egg or raw yolk of egg with sugar may also be given. 

The interval between each feeding must be prolonged, owing to the 
subnormal condition of the digestive tract. If children are fed from 
the bottle, or if they are nursing babies, then they should be fed with a 
longer interval than previous to the time of this illness; for example, if 
the infant has been given the breast every three hours, it is a good rule to 
extend the nursing time to three and one-half or four hours, if it is pos- 
sible. In this manner we will not only aid in the assimilation of the food, 
but frequently prevent stagnation of milk which had been previously taken. 

Night Feeding. — The rule which governs the feeding of healthy chil- 
dren cannot be applied to children suffering with pneumonia. During the 
febrile stage large quantities of liquids are demanded. In order to overcome 
the cardiac depression good nourishment is indicated. A nursling suffering 
with pneumonia should be given the breast several times during the night. 
Bottle-fed infants may also receive some nutrition every three or four hours 
during the night. A favorable termination in this disease can only be 
expected when the depressed vitality is stimulated by nutrition. 

Tuberculous Pneumonia. 

There are four pathological conditions which illustrate the various 
stages of the disease; they are: first, a bronchitis with rhonchi scattered 
through the chest ; second, small areas of consolidation ot partial consolida- 
tion; third, complete consolidation with bronchial breathing, dull areas 
on percussion; fourth, excavation with cavernous or amphoric breathing. 

In its early stages the disease resembles broncho-pneumonia. 

Cavities are frequently found post-mortem. They are difficult to find 
in young children under 3 years of age. On the other hand, children over 
8 or 9 years have cavities which can be recognized as early as in the adult 



TUBERCULOUS PNEUMONIA. 515 

Holt states that "the reason why in infancy cavities are so seldom recog- 
nized during life, is because they are generally small, often centrally located, 
nearly always filled with thick pus or cheesy matter, and rarely communicate 
freely with the bronchi. On the other hand it is very common to find 
signs in young children which, if heard in adults, would be regarded as 
almost positive evidence of a cavity, although none is present. These 
signs are cracked-pot resonance and cavernous breathing. They are not 
usually due to bronchiectasis, since this condition belongs to chronic cases, 
and especially to older children, but most frequently to consolidation about 
a large bronchus superficially situated, viz. : below the clavicle, high in the 
axilla, and in the interscapular region. The wide area over which this 
broncho-cavernous breathing is heard is one of the most striking points of 
difference from the signs of a cavity." 

Course. — There are two types of cases: First, rapid cases or those 
terminating very quickly; second, those assuming a chronic course (pro- 
tracted cases). 

1. The Rapid Type. — The pathological process is a bronchitis affecting 
the smaller tubes surrounded by areas of consolidation. These lesions are 
the same as are found in broncho-pneumonia. The temperature curve is fre- 
quently the same as found in broncho-pneumonia, ranging between 100° and 
104° F. The areas of consolidation are more frequently found in the upper 
lobes. There is also broncho-vesicular breathing and bronchophony. Per- 
cussion note shows slight dullness. The cough may assume a paroxysmal 
character similar to whooping-cough. Convulsions and frequently menin- 
geal symptoms, such as a slowness of the pulse or Cheyne-Stokes breathing, 
will show the extension of the disease to the brain. 

2. Those Assuming a Chronic or Protracted Course. — The duration 
of this form of the disease may be between one and six months. Some cases 
may last but three months. This is the most common type of the disease 
seen. Cases are frequently seen following measles, whooping-cough, pneu- 
monia, or diphtheria. Those cases I have seen ended fatally within three or 
four months. There is usually a slight improvement after the second or 
third week of this disease. The temperature falls and the physical signs 
seem to disappear. As a rule the disease reappears with more violent symp- 
toms, and emaciation, fever, and sweating continue until the end. The 
temperature curve is not regular. In some cases it ranges between 99° and 
101° F. Other cases will have a much higher temperature, the thermometer 
registering 104° F. frequently. Expectoration is rarely seen in young 
infants as' they invariably cough and swallow the same. The breathing 
is usually labored, hence dyspnoea is almost always present. When we 
have Cheyne-Stokes breathing, or irregular breathing, with a slow pulse, 
then cerebral complication should be suspected. 



CHAPTER V. 
ACUTE TUBERCULOSIS (MILIARY TUBERCULOSIS). 1 

Tuberculosis is a specific infectious disease caused by invasion of the 
tubercle bacillus. The disease is disseminated by the same. 

Etiology. — Acute miliary tuberculosis is frequently seen in very young 
children. I have seen cases in bottle-fed infants under 1 year of age. It 
is also frequently associated with tubercular meningitis. As a rule it fol- 
lows those diseases which devitalize the system, such as the acute infec- 
tious diseases. In prolonged diseases affecting the air passages, tubercu- 
losis frequently follows. 

Cows' Milk. — The majority of cases of tuberculosis are found in chil- 
dren brought up by artificial feeding. This implies that such children 
received cows 5 milk. The dangers of infection by or with the tubercle 
bacillus can usually be excluded inasmuch as nearly every woman boils the 
milk. The more modern woman of to-day. instead of boiling cows' milk, 
submits the food to a steaming process, either by using a sterilizer or a 
pasteurizer. The result is the same, namely, the destruction of pathogenic 
bacteria of all kind, including the tubercle bacillus. Such artificial feeding 
with cows' milk frequently results in gastro-intestinal derangement. Dys- 
peptic attacks rob the system of food required for the nutrition of bone, 
muscle and other organic structures. When such conditions persist then 
poor foundations are formed, resulting in rickets or marasmus. The tuber- 
cle bacillus easily gains entrance where subnormal conditions prevail, and 
secures a foothold that ultimately develops tuberculosis. 

Woman's Milk. — Human milk is intended by nature for the nutrition 
of infants. It offers decided prophylactic substances to the nurslings, for 
example: the nursing infant is very rarely afflicted with diphtheria or 
similar infectious diseases. This is most probably due to the immunity 
conferred by human serum and the antibodies or bacteriolysins which the 
serum contains during the nursing period. This also accounts for the 
rarity of pulmonary tuberculosis in children reared on woman's milk. The 
value of human milk has frequently been noted by me while studying this 
question in a children's clinic patronized by people living in the most con- 
gested district of Xew York City. 

The statistics of my cases of tuberculosis from the children's service 
of the German Poliklinik in Xew York City are very interesting. Five 
thousand children were examined at random for the presence of tubercular 



1 Tuberculosis of the bones 3 joints, and glands are described under separate 
articles. 

(516) 



Tl BERCI LOSIS. 517 

Lesions. More than L900 eases out of this number showed no sign of pul- 
monary disease; 1700 of these cases Buffered with adenoids, pharyngeal 
disease, catarrh of the naso-pharyngeal tract, or infectious conditions due 
to poor ventilation and general unsanitary surroundings. The cases were 
taken in children from the first to the tenth, year inclusive; 59 cases out 
of this whole number showed distinct evidence of pulmonary tuberculosis. 
Only 9 cases of this whole number showed the presence of tubercle 
bacilli in the sputum. The difficulty in procuring sputum was an obstacle 
in making more frequent examinations. Forty-three cases of this number 
had bone and joint tuberculosis in addition to evidences in the lungs. In 
two cases tubercular empyema was found. Five of these 59 cases had 
Pott's disease. 

Table Xo. QQ.— Table showing Manner of Feeding in 59 Consecutive Cases of 
Tuberculosis, among the Poor. 
Manner of Feeding. Number of Cases. 

Breast milk (human milk) . » 2 

Cows' milk 37 

Condensed milk 18 

Modified milk (laboratory) 2 

Tuberculosis in children is so closely allied to scrofulosis that a great 
many authors believe them to be identical. There certainly are a great 
many characteristics common to both. On the other hand a close scrutiny 
of the pathology of the disease will show them to be distinctly separate. 
That scrofulosis will frequently be the medium through which, later on, 
tuberculosis develops, is well known and recognized. 

"In the tuberculosis of the new-born evidence shows that the maternal 
ovum may be infected from the mother, or by the paternal seminal fluid; 
later the embryo may be infected by the placental route or amniotic fluid 
when the mother is tubercular. These modes of infection, while theoretic- 
ally possible and occasionally actually authenticated, are nevertheless ex- 
tremely infrequent in practice. By whichever of the above-mentioned routes 
the bacillus has gained entrance to the fcetal organism, there is no doubt 
that it may invade it and remain latent therein for an indefinite period. 
Unless the bacilli are actually found within the tissues, it is ex- 
tremely difficult to uphold the view that the infection has not been acquired 
after birth." 

The influence of raw meat on the evolution of experimental tubercu- 
losis has been described by Chantemesse and Cornil. 

Eichet and Hericourt published experiments showing the beneficial 
effects of raw meat in tuberculosis of dogs. Their observations were 
open to the objection that the quantity of meat given was not measured, 
and that the good effect obtained might have been due merely to the fact 



518 THE INFECTIOUS DISEASES. 

that the dogs preferred larger quantities of raw meat than they would 
have eaten of boiled. To exclude this influence the following experiments 
were made. Six couples of dogs, each of the same weight and appearance, 
were taken. One of each couple was fed with boiled meat to satiety, the 
other was given an equivalent quantity of raw meat. Both were inoculated 
in the vein of the leg with tuberculosis. The dogs fed with boiled meat 
died at intervals varying from three weeks to four months. The necropsies 
showed general tuberculosis, more or less voluminous caseous granulations, 
aud advanced fatty degeneration of the liver. Those fed on raw meat were 
killed at the same time. They were all plump : they showed less numerous 
tubercles than did the others, and less voluminous and less caseous granu- 
lations. In another experiment a dog was inoculated with tuberculosis and 
given 750 grams daily of raw meat. He preserved his strength, weight, and 
healthy appearance. He was killed at the end of twelve months. The 
necropsies showed a small number of tubercles in the viscera and tuber- 
cular interstitial nephritis. He was on the way to recovery. Two monkeys 
were inoculated with tuberculosis. One was fed on the ordinary diet, and 
died at the end of 23 days of general tuberculosis: the other was fed on raw 
meat for 15 days before the innoculation, and lived foi 49 days. 
Chantemesse and Cornil therefore conclude that the utility of raw meat 
diet in tuberculosis consisted not in overfeeding, but in the anti-tuberculous 
quality of the diet. 

The transmissibility of tuberculosis by means of drinking milk from 
cows whose udders are tuberculous, is admitted by a great many authors. 

Behring believes that milk infection remains latent for years and then 
develops tuberculosis. This he states accounts for the absence of the dis- 
ease in very young infants. 

Koch is authority for the statement that "bovine tuberculosis is an 
entirely different disease from human tuberculosis, and cannot be trans- 
mitted from a con; to a human being:' 

TVestenhoerTer believes that caries of the teeth and innamed gums, as 
seen during dentition, permit the invasion of the tubercle bacillus into 
the lymph channels of the neck, resulting in cervical, bronchial, retrosternal, 
tracheo-bronchial. and finally mesenteric tuberculosis. 1 

Chiari. of Vienna, and Freudenthal. of Xew York, believe that the 
retropharynx which harbors adenoids is the point of entrance of the tubercle 
infection. This view has always been held by me, inasmuch as tubercular 
meningitis results most probably from an extension upward from the 
pharynx, and downward, the infection enters through the cervical glands. 

Contact of the delicate, perhaps abraded, skin or mucous membrane 



Berlin Klin. Woch.. Febmarr 15. 1904. 



TUBER* ULOSIS. 519 

of the young infant with tuberculous Bputum may result in inoculation, as 
has been repeatedly shown in connection with ritual circumcision. 

The interesting observations of Lehmann show that sucking the wound 
after the ritual circumcision of Jewish children has caused tuberculosis. 
Baginsky reports a case of the transmission of tuberculosis to the eyebrow 
of a child by a tuberculous person. That tuberculosis may be transmitted 
by the pi - : vaccination on the arm cannot be disputed. 

There must be a certain disposition or predisposition to the develop- 
ment of this disease. Other factors which are prominent in this connec- 
tion are poor hygienic apartments : rooms in which sunshine is absent and 
in which foul air stagnates will certainly lower the normal resisting power 
of any and all individuals. When a child has passed through an acute 
infectious disease which has already lowered its vitality, then an infection 
with tuberculosis is more easily accomplished. Among such diseases which 
predispose to the development of tuberculosis are whooping-cough and 
measles. The same is also true in exhaustive diseases which drain the 
vitality of children for a long time. as, for example, after a prolonged 
attack of summer complaint. The disease frequently accompanies the 
nursing period, hence even the youngest child may become infected. 

Tuberculosis has so great a tendency to generalize itself in children 
that the question of the primary infection is not to be settled by the mere 
frequency of the lesions. The fact that children swallow their sputa is to 
be kept in mind. There is no question as to its infectiousness, while that 
of infected milk in the human species has not been absolutely demonstrated. 
Still's statistics show that in 25 cases taken consecutively, of 
children under 3 years, who did not expectorate, intestinal lesions were 
found in 19, while in a similar series, aged between 3 and 12, they were 
found in only 10. It would thus appear that autoinfection by the sputa in 
infants is a matter of serious importance. 

Bacteriology. — The germ can be traced to the blood and also the cells 
of the blood-vessels. This has been proven through studies made by Dou- 
trelepont, Lustig, Meisels, and TVeigert. 

Denirne found this specific germ in pus exuding from an eczema : the 
same is true about pus in otitis. Tuberculous affections of the tongue, of 
the nasal mucous membrane, of the thorax and tuberculous swellings on 
the lips of young girls have been described by Tolkmann. Primary tuber- 
culosis of the thymus, of the heart, and of the vaginal mucous membrane 
have been published by Demme. A. Baginsky has described a ser: es 
. - - of tuberculous perityphlitis, peritonitis, and enteritis. Tuberculosis 
of the testicles in children has been seen and observed by him. The so- 
called scrofulous inflammatory conditions of the joints and suppurative clis- 
- - of the bones, while being described as ••scrofulous.''* are usually of a 
tuberculous nature. The internal organs surfer from the invasion of the 



520 THE INFECTIOUS DISEASES. 

tubercle bacillus in this connection. The lungs and the pleura, the peri- 
cardium and myocardium, the liver, spleen, and kidneys, the coverings of 
the brain, and the brain itself are frequently affected. 

The question of the transmission of the tubercle bacillus is one that 
is still debatable. Thus Jani reports in Virchow's Archiv, Bd. 103, p. 522, 
that the seminal fluid of tuberculous persons contains tubercle bacilli. The 
cases of tubercles in the foetus are described by Johne and Armanni. 1 Bang, 
Lehmann, Birch Hirschf eld, Eindfleisch, and Kossel are among those who 
have reported isolated cases of tuberculosis directly transmitted from 
parent to child. Hochsinger recently reported 3 cases which he describes 
as congenital tuberculosis. These cases were associated with syphilis, and 
he believes that this disease is far more frequently transmitted than is gen- 
erally recognized. Thus it appears from the studies of Brandenberg, Lesage, 




Fig. 158. — Tubercle Bacilli and Micrococcus Tetragenus (sputum). 
Gabbet's stain, Leitz ocular I, oil immersion Via- ( a ) tubercle bacilli; (b) 
micrococcus tetragenus. ( Lenhartz-Brooks ) . 

and Wolff that the placenta is an exceedingly valuable culture medium for 
this specific micro-organism, and thus they account for the com- 
parative freedom of the foetus born to a tuberculous mother. 

Cornet and, more recently, Fliigge made extensive investigations show- 
ing the means of dissemination of the tubercle bacillus. We are indebted 
to them for our knowledge regarding the danger of sputum of a phthisical 
patient, and also regarding the manner of transmission of this disease. 

How susceptible very young children are can be shown by a case pub- 
lished by Wassermann, 2 in which he reports the transmission of tubercu- 
losis to a child six weeks old by being in contact in the same room with a 



1 Tenth International Medical Congress, Bd. 5. 

2 Zeitschrift f . Hygiene, p. 353. 



TIBKIK I LOSIS. 



521 







Fig. 159. — Tuberculosis. Horizontal 
section through the tuberculous lower lobe 
of the right lung of a two-year-old child. 
(a) caseous focus in the region of the an- 
terior border; fb) nontuberculous poster- 
ior border; (c) transverse section of bron- 
chus; (cl.d 1 ) caseated lymph glands; (e) 
pulmonary vein ; (f) point of adhesion of 
the van e with the lymph gland d 1 ; (g) 
tubercle in the lymph vessels of the 
lung parenchyma; (h) periarterial; (i) 
peribronchial; Ck) perivenous tubercles; (I) lymph vessel tubercles of the 
pleura ; (m) tubercle in its connective tissue of the hilus of the lung. X3. 
(Ziegler.) 



522 THE INFECTIOUS DISEASES. 

phthisical patient for eight days. Kitasato 1 reports the fact that tubercle 
bacilli die rapidly in the sputum, and he therefore does not believe the 
clanger of the transmissibility of tuberculosis is as great as has been claimed. 
That contact with tuberculous patients is a very serious matter can be seen 
by a study of the literature. 

Mother's milk has been closely studied and the possibility of infection 
through this channel cannot be denied. 

Pathological Anatomy. — We are indebted to Bayle, Buhl, Laennec, and 
Virchow for the division and study of the pathological anatomy of this 
disease. These authors divide the conditions into two distinct parts : First, 
cheesy pneumonia; second, the real miliary tuberculosis. By the cheesy 
pneumonia is meant that form of a chronic destructive process ending in 
cheesy necrobiosis. By the miliary tuberculosis is meant that form of dis- 
ease commencing as a tiny nodular swelling, which starts in the connective 
tissue and is associated with the lymph bodies, having a tendency to form 
broken-down cheesy masses. The pathology of this disease can certainly be 
associated with no greater name than that of Virchow, to whom we are in- 
debted for the bulk of our knowledge of this disease. 

The tubercle is a small, grayish-white, translucent, sometimes yellowish 
body. The greatest masses consist of small, round cells about the size of 
a red blood-corpuscle, and large cells resembling epithelium. There are 
also giant cells. The giant cell, as a rule, can be found in the middle of 
these tubercles and is so closely identified with this condition that it has 
been looked upon as characteristic of this disease. 

The growth of the tubercle consists in the development of new masses 
arising from the giant cells. In these giant cells there are no blood-vessels, 
and as there is no nutrition they easily break down and form what is later 
on the beginning of cheesy masses, which, by absorption and a melting 
process, are the real beginnings of cavities. At times these masses result in 
chalk deposits. The question of the specific origin of the disease has been 
finally settled by the investigations of Koch, who proved the specific micro- 
organism known as the tubercle bacillus to be the pathological factor. 

Biedert found 16 cases of primary intestinal tuberculosis among 3104 
post-mortems. 

Heller found 7.4 per cent, of primary tuberculosis among 714 post- 
mortems in diphtheria, and a total of 19.6 per cent, of all varieties of 
tuberculosis among these 714 cases. 

Orth states that primary intestinal tuberculosis is exceedingly rare in 
Berlin because of the universal use of sterilized or boiled milk. 2 



1 Zeitschr. f. Hygiene, Bd. 9, 1892, Heft 3. 

2 1 have collected and described a series of important observations on the 
association of cows' milk with tuberculosis. The pathology of the cow's udder and 
the milk ducts are also described. (See chapter on "Cows' Milk.") 



TUBERCULOSIS. 



523 






Baginsky reports that he found 8 cases of tuberculosis that died among 

ST1 nurslings at his Berlin hospital. These were all under ten months <>l 
age. On the other hand he found, among 266 children in the second year, 
13 died of miliary tuberculosis. One hundred and eighty-two children out 
of (ill died of miliary tuberculosis between the age of 2 and -1 years. Out 
of 152 children examined between the age of 4 and 6 years, 6 had miliary 
tuberculosis. 




Fig. 160. — Acute Pulmonary Miliary Tuberculosis (Cut Surface of the 
Lung.) (a) so-called obsolete tubercle (old encapsulated caseous focus), fb) 
induration, (c) caseous, partly agminated nodules (transverse section of 
caseous bronchi.) (d) submiliary noncaseated tubercle in the true lung 
tissue, (e) tubercle of the pulmonary pleura. One half natural size. (Lang- 
erhans.) 



Still 1 considers these facts and offers some interesting statistics, based, 
not on clinical observation, but on post-mortem findings, for the solution 
of this problem. In 769 autopsies of children, tubercle was found in 269, 
or 35.2 per cent. Tuberculosis was the actual cause of deaths in 252, or 32.8 
per cent. From these statistics, therefore, it can be roughly estimated that 



1 Clinical Journal, London. 



524 



THE INFECTIOUS DISEASES. 



about one-third of the deaths in childhood are due to tuberculosis in one 
form or other. While children are thus shown to be specially subject to 
this disease, they are not equally so at all ages, for Still shows that up to the 
age of -i the percentage is as high as 71, and between -4 and 8 is still 22.5; 
after 8 it diminishes to 6.5. Moreover, the greater part of the tuberculosis 
under the age of 4 — 43.4 of the 71 per cent. — occurred in children under 
2 years of age. This great frequency of tuberculosis in infancy has been 
used as an argument in favor of the idea of infection through milk, the 
primary lesion being in the digestive tract. It is true, Still says, that in- 
testinal tuberculosis is exceedingly common in children; it existed in 52 
per cent, of his cases examined, but so also is that of the brain and meninges 
— -IS per cent. — and that of the lungs is far more frequent — 78 per cent. 

TABLE No. 67. — Deaths from Phthisis Pulmanalis (Pulmonary Tuberculosis) in 
Children Under 15 Years in Old New York City. 







Total 



Years. 


l 

Year. 


2 
Years. 


3 
Years. 


Total 
v 4 Under _ ° 
lears. 5 years. ^ ears 


10 
Years. 


1890 


Males . . . 
Females . . 


* 98 
145 


30 
31 


24 

23 


10 

12 


5 

7 


7 
2 


76 
75 


14 
25 


8 
45 


1891 


Males . . . 
Females . . 


91 
119 


27 
25 


15 
16 


7 
9 


7 
3 


5 

4 


61 

57 


13 
16 


17 
46 


1892 


Males . . . 
Females . . 


109 
114 


32 
29 


29 

21 


15 
10 


6 

8 


3 85 
5 73 


17 
22 


39 


1893 


Males .... 
Females . . 


119 

143 


31 
29 


27 
17 


8 
11 


10 

7 


8 
9 


84 
73 


14 
20 


21 
47 


1894 


Males . . 
Females . . 


108 
102 


31 
20 


18 
15 


10 
10 


8 

7 


6 
3 


73 
55 


20 
12 


15 
35 


1895 


Males .... 
Females . . 


117 
122 


45 

26 


29 

27 


12 
6 


5 

7 


5 
3 


96 
69 


6 

18 


15 
35 


1896 


Males - . 
Females . . . 


87 
113 


24 

21 


26 
15 


7 
13 


5 
5 


1 
3 


63 

57 


14 

18 


10 
38 


1897 5, Iales 1 ' ' * 
Females . . 


93 

104 


28 
23 


24 

17 


8 

7 


3 
6 


2 65 • 11 
10 , 63 14 


17 

27 


1898 


Males . . 
Females . . 


84 
92 


29 
13 


18 
12 


4 
9 


3 
5 


2 
5 


56 
44 


14 
17 


14 
31 


1899 


Males .... 
Females . . . 


110 37 
117 28 


16 
13 


10 
12 


9 

10 


5 
4 


77 

67 


11 
17 


22 

33 


1900 


Males . . . 
Females . . 


108 i 28 
87 1 11 


22 

10 


16 
6 


8 
7 


5 
5 


79 
39 


13 
22 


16 
26 


1QA1 Males . . . 
1JUi Females . . 


94 

106 


25 19 

18 i 17 


8 
7 


7 
4 


5 

7 


64 16 14 
53 12 41 



Total for 10 Years, 2579 



ITBHIU IL0S1S. 



525 



The total number of deaths reported as due to consumption in the 
United States during the census year, was 109,750, of which 53,G2G were 
males, and 56,124 were females; and the ratio of deaths from this disease 
to 10(H) deaths from all known causes was 109.9. In 1890 the correspond- 
ing ratio was 122.3. 

The death rate of the colored from consumption was nearly three times 
that of the whites, and that of the foreign whites was much higher than 
that of the native whites. For the last-mentioned class the death rate for 
those having one or both parents foreign, was also much higher than for 
those of native parents. 

The death rate of males from this disease was considerably higher than 
those of females. 

The total number of deaths reported as due to consumption in the 
United States in children under 15 years of age, during the census years 
1890-1900, was 8051, of wdiich 3554 were males, and 4497 were females. 



Table No. 



Registration States. 


Total. 


Cities. 


Rural. 


r, ■ 1900 

Connecticnt -.g O0 


168.3 
233 6 


182.7 
272.6 


141.8 
205.8 


District of Colnmbia -.qoq 


305.3 
359.0 


305.3 
359.0 




AT . 1900 
Maine 1890 


164.9 


191.7 


159.4 


, T , ' 1900 
Massachusetts \P&(\ 


186.2 
267.1 


193.7 
279.4 


162.5 
227.0 


Michigan 1900 


100.7 


116.7 


94.1 


^e\v Hampshire \P&0 


152.3 
193.6 


176.2 
191.9 


137.3 
194.3 


New Jersey -j 890 


180.1 
234.5 


202.2 
268.9 


151.1 
189.4 


New York 1890 


194.1 

247.7 


221.4 
306.6 


137.3 
152.3 


™ 1 T 1 A 1900 

Rhode Island \9ftf\ 


195.3 
266.6 


208.3 
294.9 


170.0 
227.6 


~ . 1900 
Vermont 1890 


152.5 

198.8 


160.9 
243.9 


151.2 
194.7 


Total 1890 


175.9 
249.0 


204.8 
293 5 


134.1 
181.0 



This table shows that the death rate from consumption in the registra- 
tion States was higher in the District of Columbia (305.3), which was due 



526 



THE INFECTIOUS DISEASES. 



mainly to the large colored population. The next highest rate in the regis- 
tration States was in Bhode Island, where it was 195.3. The death rate 
from this disease was higher among males than females in the cities, but 
lower in the rural districts. Excluding the District of Columbia, the high- 
est occurred among males in the city of New York (265.3), and the lowest 
among males in the rural districts of Michigan. 

The following table shows that the death rates due to consumption in 
white persons under 15 years of age were highest in those whose mothers 
were born in Italy (50.7), in France (47.1), and in "other foreign" coun- 
tries (45.9) ; and were lowest in those whose mothers were born in Poland 
(11.4), in Bohemia (13.2), and in Germany (26.6). 

Table No. 69. 



Color and Birthplaces of Mothers. 



Under 15 Years. 



White 

Colored 

Mothers born in — 

United States . . 
Ireland 

Germany . . 

England and Wales 
Canada .... 
Scandinavia . . . 

Scotland 

Italy 

France 

Hungary ..... 

Bohemia 

Russia 

Poland 

Other foreign . . 



31.8 
246.0 



27.5 
42.2 
26.6 
27.2 
34.5 
32,4 
32.9 
50.7 
47.1 
38.6 
13.2 
26.7 
11.4 
45.9 



Table No. 70. — Percentage of Deaths per IOC from Consumption in Children from 
1 to 15 years of age. ( United States). 



Age. 



1900 



Males. 



Under 1 year . 

1 year ... 

2 years . . . 

3 years . = . . 

4 years . 
Under 5 years 

5 to 9 years 

10 to 14 years . 



Females. 




1890 



Males. 



Females. 




TIHKIU V LOS IS. 



527 



Table No. 71. — Death* from Other Tubercular Diseases in Children Under 15 
Yean, — New York City. 



o 
Y"ear. 



Yr. 



2 
Yrs. 



3 
Yrs. 



4 

Yrs. 



Total 

Under 
5 Years, 



5 to 10 
Years . 



10 to 
15 

Yrs. 



Total 

Under 
15 

Years. 



1890 

Males 



Females 



1891 
Males 



Females 



1892 
Males 



Females 



Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 
Spinal .... 

Hip 

Tabes Mesenterica 
Tuber. Meningitis 
Other Forms 

Spinal 

Hip. ... 



17 

132 

52 



4 
79 

10 



9 
92 
37 



2 
70 

is 



31 

6 
2 

1 

38 
10 

2 



23 

1 
1 
1 

19 



22 

278 

71 

4 

1 

12 

222 

71 

5 

3 



24 
2 
4 
1 
3 

20 
4 
4 
3 



Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 

Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip. ..... . 



16 

118 
30 



11 

123 

35 

1 



31 



4 
75 
12 



1 

26 
4 



1 

19 
3 



29 
5 



23 
3 



12 
3 
1 

2 

11 
2 



21 
263 

61 
1 
4 

15 
261 

57 
1 
1 



1 

24 

5 

3 

5 

1 

24 

7 

4 

10 



Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 

Tabes Mesenterica 
Tuber. Meningitis 
Other Forms 

Spinal 

Hip 



12 

148 

42 



16 

115 

36 



1893 



Males 



Females 



Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip . 

Tabes Mesenterica 
Tuber. Meningitis 
Other Forms . . 
Spinal .... 
Hip 



18 

157 

32 



16 

114 

36 



Tabes Mesenterica 
1894 Tuber. Meningitis 

Other Forms 
Males SP in al . . 

Hip 

Tabes Mesenterica 
Tuber. Meningitis 
Females Other Forms 

Spinal .... 
Hip 



11 

143 

25 

1 

1 

7 

102 

27 



4 
90 
25 

1 

2 
61 
19 

1 



2 

80 
14 

1 

2 
59 

16 



5 

87 

18 

2 

4 

62 

11 



1 
28 
5 
1 
1 
2 
37 
5 



14 
5 
1 
1 

19 
1 



19 
3 
1 
1 

10 
2 
1 



17 

299 

80 

4 

3 

20 

242 

63 

2 

1 



1 

23 
4 
3 
2 
1 

27 
6 
3 
3 



1 

35 

9 

3 



23 

1 
1 



19 

2 



14 
2 
2 
1 

16 



21 
309 

58 
7 
1 

18 
233 

62 
1 
1 



1 
24 

8 
7 
4 

30 
6 
5 
1 



3 

27 
3 
3 
1 

37 

4 



20 
5 
1 



19 
4 
1 



18 



19 

295 

46 

8 

2 

12 

227 

52 

1 

9. 



35 
9 
4 
3 



5 
4 
3 

4 

1 

28 8 

13| 10 

2 3 

5 1 



22 

310 

75 

11 

3 

15 

246 

75 

10 

7 



22 

295 

71 

9 

12 
16 
288 
67 
8 
11 



18 
330 

85 

11 
9 

21 
275 

72 
9 
5 



22 

340 

70 

17 

7 

18 

267 

73 

8 



19 

335 

59 

15 
9 

13 
263 

75 
6 



528 



THE INFECTIOUS DISEASE: 



Table No. 71. — Deaths from Other Tubercular Diseases in Childrei Under 15 
Tears. — Xeic York City. — Continued). 










l 


2 


3 


4 


Total 
Under 
5 Years. 


5 to 10 


10 to 

15 
Yrs. 


Total 
Under 






Year. 


Yr. 


Yrs. 


Yrs. 


Yrs. 


Years. 


15 

Years. 




Tabes Mesenteriea 


12 


1 








13 


1 




14 


1895 


Tuber. Meningitis . 


147 


73 


38 


15 


17 


290 


17 


9 


316 




Other Forms . . . 


47 


15 


8 


2 


1 


73 


8 


3 


84 


Males 


Spinal . . . . 




1 


2 


1 


1 


5 


5 


- 


18 




Hip 


1 








1 


o 


3 




5 




Tabes Mesenteriea . 


9 


1 


1 




1 


12 






12 




Tuber. Meningitis , 


94 


61 


44 


25 


12 


336 


26 


i 


269 


Females 


Other Forms . . . 


36 


15 


9 


3 


3 


59 


9 


1 


69 




Spinal . . , . 




1 


3 


3 




i 


5 


1 


13 




Hip 


3 






1 




4 





4 


10 



1896 



Males 



Females 



Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 
Spinal . . . 

Hip 

Talnes Mesenteriea 
Tuber. Meningitis 
Other Forms 

Spinal 

Hip 



9 
102 

47 



1891 



Males 



Female: 



1898 



Males 



Females 



1S99 



Males 



Females 



Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms - . 
Spinal ..... 

Hip 

Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 



10 

114 
3S 



3 

102 

38 

o 



1 

75 

17 

1 

1 

4 

59 

14 



1 

73 
14 

1 

1 

1 

60 

17 



25 
6 

1 



34 
10 



30 

8 



31 

5 

1 



15 

4 



11 



12 
4 

1 



Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 
Spinal ... 
Hip ..... . 

Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 



113 
25 



10 
91 

82 
1 



23 



1 
18 

8 



24 14 
2 3 

1 1 



19 
2 



14 

1 
1 



7 

271 

58 

4 



13 
210 

52 
2 
2 



Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 

Tabes Mesenteriea 
Tuber. Meningitis 
Other Forms . . 

Spinal 

Hip 



102 

13 



o 
96 
26 



70 
11 



1 

69 
15 



3S 
10 



27 
5 

1 



19 

7 



1 

21 

5 



12 
3 



16 
3 

1 



24'3 
44 

1 
7 
229 
54 
2 
1 



36 

o 
jjj 

23 
5 

2 







11 






15 


22 


252 


22 


8 


3 


6 


79 


11 


7 


2 


3 


6 


5 




1 


1 


3 


3 


2 




, 


17 


1 




18 


15 


302 


23 


4 


7 


4 


57 


11 


11 




1 


4 


Q 

a 

3 


1 
1 



18 7 

8 3 

2 3 

1 . . 

27 5 

14 12 

4 1 

2 1 



11 


1 




253 


23 


4 


69 


11 


11 


4 


5 


4 


1 


3 


1 


4 






209 


24 


4 


71 


12 


4 


3 


2 


4 



11 

>S2 

07 

11 

8 

18 

529 

79 

8 

4 



12 

os.;, 
91 
13 

5 

4 

237 

-7 

9 

9 



s 

300 

69 
6 
3 

13 

24" 



9 

271 

55 

5 

2 

7 

261 

80 

7 

4 



11 BER< I LOSIS. 






Tablk No. 71. 



•Deaths firem Other Wbercmkar 1> - 

York City. — (Cottti/ii- 









l 

Vr. Vrv 


3 


4 
Yrs. 


Total 
Under 
5 Years. 


" 


Tra. 


Males 
Females 


Ikbea Mesenteries 
Tuber. Meningitis . 

Other Forms . . . 
Spinal ... 
Hip ... . 


7 

a 


g 

82 

1 


1 
43 

7 


21 

4 


10 

4 


10 

4:t 

3 

8 
212 

. 

1 
1 


27 
13 

5 

4 
2 
2 


1 
8 388 

4 7 


Tabes Mesenterica . 

Tuber. Meningitis . 
Other Forms . . . 

Spinal 

Hip ....... . 


5 

18 


3 

59 

7 

' 1 


24 

4 


22 

1 

12 
' 1 

' 1 

1 

20 

1 

1 

' 1 

1 


11 
2 

1 
. . 


8 
10 252 

10 46 

1 4 

1 I 4 


Tuber. Meningitis . j 96 
1901 Abdominal Tuber. . < 13 
Pott"< Di>e;v<e 


5 
5 

1 
1 

5 
48 


28 
3 

1 
5 

•29 

1 

5 


13 

1 
1 

8 

' 1 

1 
1 
1 


2 - 

22 

3 

1 

6 

19 

184 

11 

g 

1 

4 

15 


25 

4 


G 


3 


Males 
Females 


Cold Abscess ..... 


2 
9 

7 

24 
2 
2 
2 

4 




' 1 
6 

1 

10 
3 

2 

4 


1 


White Swelling 
Tuber, of Other Org. 
Oeneral Tuber. . . 

Tuber. Meningitis . 
Abdominal Tuber. 
Pott's Disease . . . 
White Swelling 
Tuber, of Other Org. 
General Tuber. . 


4 
8 

78 
9 


3 

21 
27 

218 

16 

4 


6 


i 

2 


2 

10 

•21 



J. Walker Carr reports statistics of necropsies on tuberculous 

children at the Victoria Hospital. He found T9 in which the disease most 
probably started in the chest, and 20 in which it seemed to have begun in 
the abdomen. Here the relation between the two forms of infection is as 
1 to 4. In 26 children of early or limited tuberculosis, the thorax alone 
was affected in 12 cases, the abdomen in 7, being in the proportion of 1 to 
1.7. Of 53 tuberculous children under 2 years of age the disease most 
probably began in the chest in 43 and in only 5 certainly in the abdomen, 
the proportion in this case being a- 1 to 8.6. Out of 2? children over 5 
years of age, the disease began in the chest in 12, in the abdomen in •;'■. t 
relation being as 1 to 2. 

These statistics being all from English sources are fairly comparable. 
and it appears to me they sustain Thome's contention that the returns 
in England of tabes mesenterica represent with fair accuracy the abdominal 
tuberculosis of children. 

Bollinger, in his address at the International Tuberculosis Congress, 

of Berlin, in 1899, quoted with approval the record of autopsies by Heller 

(Kiel )of 248 tuberculous children. In 45.5 per cent, of the cases, tuber- 

From these it was concluded 
u 



culosis involved the mesenteric glands 



530 THE INFECTIOUS DISEASES. 

that milk played a leading role in the so-called transmitted tuberculosis of 
children. 

It is plain from what has been said, without quoting further statistics, 
that in some countries where bovine tuberculosis is very frequent, there is 
also a great frequency of tuberculosis in children. Bollinger concludes that 
"although the tuberculosis of cattle and swine does not stand in the first 
line as source and starting point of human tuberculosis, nevertheless — con- 
sidering their enormous distribution and progressive additions, and the great 
danger from the ingestion of the milk of tuberculous cows — they are cer- 
tainly for humanity the most important and the most dangerous of all 
animal plagues, and deserve the most earnest attention from the sanitarian 
and the state." 

Symptoms. — The more important symptoms noted in this condition are 
a general restlessness with a rise of temperature. Children frequently have 
little or no cough, but some difficulty with respiration for which no distinct 
physical signs can be found. The temperature will sometimes rise as high 
as 103° or 104° F., or it may suddenly become apyretic and assume a sub- 
normal tendency. The temperature usually seen is 101° F. The children 
appear very anaemic and at times cyanotic, mostly on the cheeks and lips. 
Emaciation usually accompanies this "intermittent type of fever." To the 
inexperienced, the beginning of a miliary tuberculosis resembles mostly the 
clinical picture which so frequently accompanies intermittent fever. There 
usually is slight swelling of the peripheral lymph glands. The spleen and 
liver will be felt enlarged. The urine will give a slight diazo reaction, also 
an indican reaction. Neither of these, however, are constantly present. We 
have what is commonly known as a "pre-tubercular anaemia," in which there 
is a general tendency to breakdown, and pallor so well marked, for which 
there is no distinct group of symptoms. When such profound anaemia 
exists with slight variations of temperature, then tuberculosis may be in- 
ferred; hence this stage is regarded by some clinicians as the "pre-tuber- 
cular" stage. Occasionally the examination of the chest shows catarrhal 
symptoms and rhonchi as accompany an ordinary bronchitis. There is an 
absence of bronchial breathing and no distinct evidence of dullness on per- 
cussion. Frequently these symptoms increase in severity. Cyanosis may 
accompany this condition and the circulation may be so poor as to show cold 
feet and hands. Death occasionally follows this condition. The clinical 
picture here given is the one that is frequently seen in that type of acute 
miliary tuberculosis running a malignant and very short course. In this 
condition the children appear very pale and lose weight. There is distinct 
anorexia which alternates with hyperorexia. Dyspeptic symptoms, such as 
vomiting and diarrhoea, may alternate with constipation. Such children 
are usually very sensitive and inclined to be peevish and cry on the slightest 
provocation. 






Tl BERCULOSIS. 531 

A study of the above Bymptoma will show that there are no distinct 
typical symptoms which can be laid down as positively diagnostic. It is 
for this reason that so main other diseases are confounded with miliary 
tuberculosis until the same has progressed considerably. When there is 
marked cachexia accompanying nurslings for which there is no distinct 
reason, and especially so if the fever accompanying the same is an inter- 
mittent type, then we should not forget the possibility of our dealing w r ith a 
ease of miliary tuberculosis. 

Case I. A child, 2 years old, was brought to my children's clinic at the New 
York Post-Graduate Medical School and Hospital, with the following history: She 
was a bottle-fed infant raised on condensed milk. The bowels were always con- 
stipated. Has had one attack of cholera infantum when eleven months old which 
caused emaciation and general atrophy. 

Present illness dates back to three months ago when child had measles fol- 
lowed by a severe broncho-pneumonia. The cough has persisted, but mostly at 
night. There was no expectoration. 

Physical Examination. — Examination reveals an emaciated, very rachitic child, 
pigeon-breasted, with decided beaded ribs. There is also a kyphosis. The abdomen 
is distended (pot-belly). The superficial veins are enlarged, the head shows 
marked frontal, parietal, and occipital rickets. Cranio-tabes is also present, so 
that we can safely call this a markedly rachitic case. At the left apex there were 
heard coarse, mucous and sonorous rales, also prolonged expiration. The right lower 
lobe had several areas of amphoric breathing, also some friction sounds and prolonged 
harsh expiration. Percussion note was dull. The morning temperature in the rectum 
was 101° F., pulse 144, respiration 40. The appetite was poor, spleen enlarged, hands 
and feet cold, and the child perspired freely. 

Diagnosis. — Tuberculosis after morbilli. 

Family History. — The father died of tuberculosis when the infant was six 
months old. The mother is still living and in apparent good health. Two other 
children in the same family show no evidence of illness. The family live in a 
rear house behind a tenement house. The weight of the child when first seen was 
sixteen pounds. 

Treatment. — An emulsion of the yolks of 6 eggs containing sugar, and 15 drops of 
creosote carbonate was fed each day. Buttermilk and the serum of bullock's blood 
was given in wineglassful doses several times a day. The child was sent to the 
country and ordered to live out of doors. The appetite improved and the cough 
lessened. From month to month the clinical symptoms gradually subsided and 
at the end of two years the physical signs in the lungs entirely disappeared, and her 
weight increased to 32 pounds. 

In this case tubercle bacilli were found in the sputum that was vomited after a 
severe coughing paroxysm. The case is well to-day. 

Case II. A girl, 12 years old, seen by me some years ago, was brought to my 
children's clinic at the New York Post-Graduate Medical School and Hospital. She 
was suffering with headache, cough, general malaise, poor appetite, and emaciation. 
She had been under the treatment of a physician who diagnosed malaria. The 
bowels were irregular, at times constipated, at other times diarrhceal. The urine, 
light amber color, contained nothing abnormal. The child perspired freely at the 
slightest exertion, even after each paroxysm of cough. 

Previous History— She was a bottle-fed infant. Had measles and broncho- 



532 THE INFECTIOUS DISEASES. 

pneumonia at 3 years. When 5 years old had had whooping-cough which lasted 
four months. Excepting an occasional cough no other symptoms were present. 

Family History. — The family history is good. Both parents are living and 
four brothers; all are healthy. The only history as to etiology is that this girl 
has lived in unsanitary surroundings, besides having a weakened state of the 
respiratory tract. 

Physical Examination, — At the first examination she appeared slightly icteric, 
the spleen was enlarged, the liver normal. There was a slight dullness at the 
apex of the right side, some mucous rales and harsh breathing. There was a slight 
expectoration, no history of haemoptysis. Nose bleeding was complained of occa- 
sionally. The diagnosis was made by the presence of tubercle bacilli in the 
sputum. Each month her sputum was examined, and it was found that the 
sputum which was expectorated during the early morning hours, between 4 and 6 
a.m., contained the greatest number of tubercle bacilli. After four months of treat- 
ment it was found that the bacilli in the morning sputum were so sparingly present 
that evidently some change was going on. The symptoms of headache and malaise 
disappeared entirely. The icteric condition disappeared. The epistaxis has not 
shown itself within the last five months. A careful examination of the sputum 
four times a month has not shown a single tubercle bacillus. 

The treatment consisted in removing the child from school and giving her a 
substantial diet of which proteids formed the chief part. The hygienic conditions 
were improved as much as the circumstances of the family would permit. 

I impressed the family with the necessity of removing the child to the country 
and she was given into the employ of a farmer, and ordered to be in the open air 
all of the time. Six months later I saw the case again. She had gained in weight. 
Her cough had ceased and the physical signs were lessened. 

The child lived in the country eighteen months. 

At the end of this time there was no evidence of cough nor of the general 
malaise excepting the physical signs on auscultation and percussion. I have seen 
this child in all about seven years and believe that she is quite healthy. The 
pulmonary symptoms have entirely disappeared. 

According to Loomis, tuberculosis and cavities in the lungs can and do heal. 
I have good reason to believe that in this patient, in whom we diagnosed apex tuber- 
culosis or a catarrhal tuberculosis affecting the apices of both lungs, this process 
was arrested in its incipiency.. 

Diagnosis. — Method of Obtaining Sputum: In infants and young chil- 
dren who do not expectorate, the following method of obtaining sputum is 
suggested by Findlay, of Glasgow: "With a piece of gauze on the fore- 
finger, the pharynx, and especially the epiglottis, is irritated so as to induce 
coughing, and any expectoration that is coughed up is swept out of the 
mouth before it has time to be swallowed. The quantity thus obtained 
varies, but as a rule is sufficient for bacteriological examination." 

The diagnosis will frequently be very difficult, especially so if no data 
can be obtained which will complete our clinical picture. If the child 
has been exposed to tuberculous individuals then a suspicion may arise (if 
there is a tuberculous family disposition) of a possibility of the development 
of this disease. Frequently the symptoms are such as to resemble typhoid, 



plate xnr 



Old Tuberculin, 
Undiluted 



Dilution— 1 : 4 



Dilution— 1 : 16 

Dilution— 1 : 6-4 

Control, Not 
Inoculated 




Cutaneous Reaction Showing the Various Results with Concentrated and 
Diluted Tuberculin. Taken 48 hours after inoculation by Dr. Henning, at the 
clinic of Escherich. 



PLATE XIV 




Severe Cutaneous Reaction. Note the two places inoculated. The centei 
is the control. (Escherich's clinic.) 




Scrofulous Reaction. Two outer places inoculated. The 
center is the control. (Escherich's clinic.) 



TUBER* I LOSI& 

but if there is an absence of roseola, if the diazo reaction is al 
and if the Widal reaction is absent, tlien miliary tuberculosis rnnsi 
inferred. The ophthal] - n must not be looked upoi. 

positive criterion, for miliary tul - - riat in spite of the al»- 

of tnbercu - - the choroid. For differential diagnosis between tubercu- 
losis and syphilis, see chapter on "Syphilis." 

din. — The use of injections of tuberculin : _ stic as well 

as therapeutic results dates bad 3 1. when Koch first announced clin- 

ical results. My experience with tuberculin at that time, through the 
court.- G _ F. Shrady, at the St. Francis Hospital. Xew Y 

was not very encouraging. I have also se^n cases in which tuberculin was 
through the courtesy of Prof. Adolph Baginsky. at the Berlin Chil- 
dren's Hospital. Baginsky has never encouraged the use of these 
injections. In his sixth edition of "Lehrbuch der Kinderkrank- 
heiten." 1- . _ 50, he say-: CC I do not believe that the injection of 
tuberculin, especially in very small children, is without danger. I 
aware that Kossel, in Berlin, uses the injections very extensively and with- 
out ill results.** He states the minimiun dose for an infant is from 1 to 
5 milligrams. 

TUBEECULIX EeaCTIOX AX AlD TO THE DlAGXOSIS OF LaIEXT 
FOEAIS OF TUBERCUEOSI-. 1 

Von Pirquet found that by inoculating the skin with a minute quantity 
of old tuberculin a local inflammatory reaction is produced. There is no 
fever nor general systemic disturbance after such inoculation. TViii: 
older method of Koch fever followed each injection. The technique is as 
follows: Wash the arm with ether and scarify three small areas, but not 
enough to produce a bloody surface. Into two of these scarified areas inocu- 
-imilar to vaccination) diluted tuberculin of the strength of one part 
tuberculin with three parts normal saline solution. Leave the third scari- 
fied area without inoculation as a control. After twenty-four, rarely later 
than forty-eight hours, a local inflammatory reaction, about 10 millimeters 
in width, surrounding the inoculated area, denotes a positive reaction. In 
the last stages of miliary tuberculosis and tuberculous meningitis no reaction 
follows. The ophthalmo reaction 2 is another method of diagnc sis. 

Prognosis. — The success attained during the last few years" in the 
treatment of tuberculosis proves the scientific progress made. Several years 
ago this disease was erroneously considered hopele— . 

1 Complete literature and details published iu the Xew York Medical Journal, 
October 19. 19 1 

: Cahnette advises using a 1 ' : , per cent, dilution of tuberculin dropped into 
the eye. 

3 'Tuberculosis and How to Combat It." prize essay by S. A. Knopf, is well 
worth reading. 



534 THE INFECTIOUS DISEASES. 

Modern physicians recognize the importance of treating the collapsed 
lung that has become so through unsanitary surroundings, in the light of 
cause and effect. The prognosis therefore will depend on the age of the 
patient, the stage of the disease in which treatment is commenced, and the 
will power of the patient. The vitality of children and their ability to pass 
through long periods of illness and finally recover should be remembered 
when the outcome of the case is considered. Severe forms of marasmus, 
with marked emaciation, apparently hopeless, finally recovered. I have also 
seen severe forms of apex tuberculosis in children that entirely recovered 
after proper hygienic and dietetic treatment was instituted. 

It is our duty to instruct parents and those in charge of children of the 
dangers on the one hand where treatment is neglected, and to picture to 
them on the other hand how successful other cases have been when the dis- 
ease was properly handled. 

Treatment. — Dietetic Treatment: Next to sunshine, fresh air, and 
pulmonary gymnastics comes nutrition. A child that is properly strength- 
ened with milk, buttermilk, cocoa, eggs, cereals, cheese, green vegetables, 
fruits, meats, and meat broths will certainly be better able to recover than 
one that is underfed. 

One Point Concerning Feeding. — Milk if given should not be repeated 
oftener than once in four hours. The yolk of a fresh egg may be added 
just before feeding. When soup is given the yolk of a fresh egg may be 
added to it. I frequently give the yolks of eight or ten eggs in twenty-four 
hours if the gastric condition warrants the same. 

Strict attention must be paid to the bowels so that we do not overfeed 
and produce a dyspepsia by overfeeding. If milk is not well borne it may 
be peptonized. 

General Treatment. — In the treatment of tuberculosis the most im- 
portant point to remember is that fresh air is the best lung disinfectant 
that we possess. No remedy will kill tubercle bacilli as quickly as sunshine 
and fresh air. This should be impressed on every family wherein a case 
of tuberculosis is found. The progress made in recent years by climatic 
treatment has demonstrated the fact that cavities in the lung will frequently 
heal under proper treatment. The open-air treatment has gained such a 
strong foothold that we do not encounter the same difficulties that we did 
years ago when recommending open windows night and day. The great 
bugbear of night air should be removed, because fresh air at night is equally 
as important as it is by day. 

Hygienic Treatment. — The value of- sunshine, fresh air, and outdoor 
life, best known as the hygienic treatment of tuberculosis, must not be 
forgotten. To cure any case of tuberculosis by an indoor life is out of the 
question. When exercise can be taken it should be insisted upon, as thereby 
we stimulate metabolism and increase the power of assimilating food. 






TUBERCULOSIS. 535 

Pulmonary Gymnastics. — Deep inspiration and expiration will oxy- 
genate the lungs when regularly performed. 

Deep breaths taken in the mountains on which there are pine-needle 
tree* will Jo niore toward expanding and impregnating diseased or collapsed 
portions of the /ana than will the inhalation of a hundred times that quan- 
tity of pine-needle oil in the close stuffy room when diffused from an atom- 
izer. The hygienic treatment must not be confined to walking and breath- 
ing the pure air, but must be aided by tepid bathing and by stimulating the 
circulation of the blood by friction with a coarse Turkish towel. Sea salt 
can be added to the bath. When the feet or hands are cold they should be 
briskly rubbed until the blood circulates freely. 

Medicinal Treatment. — Codliver-oil internally should be tried. If it 
is not well borne it can be used by external friction over the whole body, 
daily for ten or fifteen minutes. This is the so-called codliver-oil bath. 
If codliver-oil is not tolerated, butter should be given in large quantities. 
Codeine in 1 / 10 to 1 / 4 -grain doses can be given, or heroin in 1 / 50 to V 25 - 
grain doses, three times a day, may be given to relieve cough. For the 
relief of the night sweats sulphate of atropine, 1 / 150 to 1 / 100 of a grain, 
three times a day, should be given. Toxic symptoms should always be 
looked for in the pupils when administering these drugs. A laxative dose 
of citrate of magnesia or calcined magnesia, 5 to 10 grains, several times a 
day, is useful. Creosote carbonate, 5 to 20 drops, three times a day, given 
in the form of an emulsion, has served me very well. 

I£ Creosote carbonate 1 drachm 

Mucilage acacia 1 ounce 

Emulsion aniygd. dulc q. s. ad 2 ounces 

Sig.: One drachm three or four times a day. 

If blood is expectorated, then 5 to 15 drops of fluid extract of ergot 
can be given every few hours. In other cases 5 to 10 grains of powdered 
alum, repeated every few hours, may do good. I have also seen good results 
from 5 and 10-grain doses of gallic acid. Fluid extract of hydrastis cana- 
densis, 3 to 10 drops, several times a day, or hydrastinine hydrochlorate, 
Vioo grain, three times a day, may be tried. 

Tincture of iron in 5 to 10-drop doses, is a good hemostatic; besides 
it is a valuable tonic. Stimulation is sometimes required. Old rye whisky, 
wine or champagne is indicated. It not only stimulates but promotes the 
appetite in debilitated cases. 

Chronic Pulmonary Tuberculosis. (Tuberculous 
Broncho Pneumonia.) 
This condition is rarely found in infants and very young children. 
When chronic pulmonary tuberculosis is noted it is usually seen in children 
after the sixth or eighth year. 



536 



THE INFECTIOUS DISEASES. 



Pathology. — Osier states that small cavities are by no means rare in 
chronic pulmonary tuberculosis of children, bnt very large excavations are 
rare: thus in 265 cases noted by Barthez and Sanne there were 77 cases 
with excavation, chiefly in the upper lobes. In the analysis by Leroux of 




Fig. 161. — Fever curve during the early period of Chronic Pulmonary 
Tuberculosis. The daily excursions are slight, and generally range between 
102° and 104° F. (Original.) 

the cases of the late Parrot, in 219 children under 2 years of age, 
there were 57 instances in which cavities existed. In five of these the 
children were under three months. In long-standing cases hard, firm, 
fibrous tubercles are found, and sometimes cutaneous nodules. The pri- 




Fig. 162. — Temperature curve during the fifth month, when the disease 
is more extended and softening has taken place with the formation of cavities. 
The temperature is more hectic in character. The morning temperature 
may be normal or subnormal, while the evening temperature ranges between 
103° and 105° F. (Original.) 



mary lesion in a great majority of instances is a tuberculous broncho- 
pneumonia, taking its origin in the smaller bronchioles, leading to peri- 
bronchial nodules and subsequent peribronchial alveolitis. The lesions are 



XI r>i:i;n LOSIS. 



537 



similar to those mei with in the tuberculosis of adults — miliary tubercles, 
peribronchial nodules, caseous blocks, areas of softening and of fibroid 
induration, and cavities of various sizes. Wo do not see so frequently the 
invasion of the lung from the apex downward. The chief scat of disease 




Fig. 163. — Chronic Nodular Tuberculous Broncho-pneumonia, (a, 1), c, d) 
tuberculous foci of variable size and shape, corresponding to the infiltrated 
alveolar system; (e) transverse section through an infiltrated occluded bron- 
chiole; (f) small arterial branch; (g) group of nodules undergoing coales- 
cence; (h) small unaltered bronchus ; (k) artery. X6. (Ziegler.) 



may be in the central portion of the lung, or even at the base. In tuber- 
culosis of the lymph glands, the groups along the trachea and about the 
bronchi may be greatly enlarged and caseous, forming on section a very 
striking feature in the chronic pulmonary tuberculosis of children. 

Symptoms. — Chronic pulmonary tuberculosis in the child presents the 
same symptoms as in the adult. Usually a broncho-pneumonia will first be 
encountered, or the symptoms present will resemble those of a broncho- 



538 THE INFECTIOUS DISEASES. 

pneumonia. When fever persists and there are evidences of a general 
breakdown, such as malaise, loss of appetite, and emaciation with or with- 
out cough, then this condition must be suspected. When these children 
expectorate, the same resembles that seen in adults. Tubercle bacilli have 
frequently been found in the expectoration of cases under my care. Blood 
spitting in which the mucus is blood-stained has been seen by me. The 
blood is bright red in color. Epistaxis is sometimes seen during the course 
of the disease. The temperature ranges between 100° and 102° F. in the 
beginning of the disease; later on it assumes the real hectic character; 
thus, the temperature may be 99° to 100° F. in the morning, and 103° to 
105° F. in the evening. 

Pleuritic pains are complained of in various parts of the chest. There 
is marked dyspnoea and frequently cyanosis. Osier states that some cases 
do not have any pain throughout the course of the disease. A general 
emaciation associated with muscular weakness and anaemia is usually seen 
later in the disease. Tubercular ulceration of the intestine will frequently 
cause diarrhoea. In a child seen by me with chronic tuberculosis of the 
lungs, a general anasarca was present. 

Katie B.., 8 years old. has been a very delicate child. She was breast and 
bottle-fed, and lived in a tenement house. 

Familij History. — The father was a drunkard and did not support his family; 
the mother is a frail anaemic woman, although no evidence of pulmonary disease 
could be found. The child was late in walking, late in teething, and late in talking. 
Distinct evidence of rickets of the bones was everywhere noted. When 4 years 
old the child had measles, complicated with broncho-pneumonia, after which a 
cough remained. Three months after the measles the child still coughed and 
showed evidences of malnutrition. The cough persisted in spite of codliver-oil, 
malt extract, and iron, which was liberally given. As the family were poor 
they could not take the child to the country for a complete change of air. I did 
not see the case again for two years, when I saw it through the courtesy of Dr. 
John H. TVurthman. At this time she had a cavity at the apex of the right lung, was 
terribly emaciated, and complained of pain on breathing and suffered with marked 
dyspnoea. Pleuritic friction sounds were heard over small areas of the chest on 
both sides. The child had haemoptysis besides a purulent expectoration. Tubercle 
bacilli were found in the sputum. She died after a violent haemorrhage, from ex- 
haustion and heart failure. 

The treatment is the same as described in the article on "Acute 
Tuberculosis." 



CHAPTER VI. 

ACUTE DIPHTHERIA. 

Diphtheria is an acute infectious disease caused by the invasion of a 
specific micro-organism known as the Klebs-Loeffler bacillus. 

It is a disease characterized by the presence, locally, of false mem- 
branes, known as pseudo-membranes. 

Etiology. — This disease is most frequently met with in children, al- 
though adults are not exempt from it. It is met with in the newly born 
(Jacobi). It is most frequently seen about the second year. Children are 
especially disposed to this disease between the ages of 1 and 5 years. Bagin- 
sky reports a series of 2711 cases in which: — 

84 occurred during the first year. 
889 between the first and fourth year. 
1411 between the fourth and tenth year. 
318 between the tenth and fourteenth year. 

There is no difference in the sex regarding the predisposition to 
diphtheria : — 

1311 in the above series were boys. 
1400 were girls. 

Infection is spread primarily by contact. It can be transmitted 
through dishes, play toys, and furniture to which the Klebs-Loeffler bacilli 
adhere. Infections have been traced to water and milk which contained 
the diphtheria bacillus. We know that the Klebs-Loeffler bacilli adhere 
to the walls and ceilings of rooms. The etiology of diphtheria remained 
obscure until Loeffler discovered the bacillus in 1884. 

Sewer gas is not looked upon as a cause of diphtheria per se. When the 
system is poisoned by sewer gas it will offer less resistance to the infection 
of the Klebs-Loeffler bacillus than otherwise. 

TJnhealtliy Throats. — The presence of diseased tonsils, or adenoid 
vegetations in the pharynx, are usually foci for the development and 
propagation of the Klebs-Loeffler bacillus.' The writer has frequently ques- 
tioned the patients at the Willard Parker Hospital regarding former throat 
diseases. It was rare to find a throat infected with diphtheria that did not 
have previous tonsillar or other throat disease. 

Thus it would appear wise to put the throat in as healthy a state as 

(539) 



540 



THE INFECTIOUS DISEASES. 



possible in order to prevent the opportunity for receiving an infection of 
diphtheria. 

False diphtheria, in which there is a non- virulent germ present, fre- 
quently resembles diphtheria. 

Hunt's differential stain and also the Neisser stain will differentiate 
the non-virulent from the virulent form of germ. 

Table No. 72. — Deaths from Diphtheria and Croup, in Children under 15 
Years — (Old) . City of New York. 









o 

lear. 


l 
Year. 


2 
Years. 


3 
Years. 


4 
Years. 


Under 
5Yrs. 


5-10 
Years. 


10-15 
Years. 


1890 


Males 
Females 


913 

843 


99 

71 


233 

188 


193 

183 


145 
162 


92 

90 


762 

691 


143 
139 


8 
13 


1891 


Males 
Females 


1000 
934 


111 

85 


232 

202 


210 
203 


173 
167 


111 
95 


837 

752 


155 
172 


8 
10 


1892 


Males 
Females 


1101 

968 


92 
67 


269 

222 


270 
205 


187 
181 


123 
108 


941 

783 


148 
173 


12 

12 


1893 


Males 
Females 


1241 

1278 


98 
110 


300 
273 


278 
276 


218 
199 


121 

137 


1015 
995 


211 
261 


15 
22 


1894 


Males 
Females 


1456 

1386 


125 
109 


351 
301 


311 
306 


253 

228 


167 
167 


1207 
1111 


233 

255 


16 
20 


1895 


Males 
Females 


1000 
946 


130 

84 


247 
232 


200 

217 


175 

138 


102 
94 


854 
765 


138 
169 


8 
12 


1896 


Males 
Females 


872 
859 


96 
65 


241 
197 


193 

188 


112 

141 


100 
101 


742 
692 


119 
151 


11 
16 


1897 


Males 
Females 


756 
811 


82 
74 


196 
213 


169 
156 


106 
122 


75 
76 


628 
641 


118 
164 


10 
6 


1898 


Males 
Females 


456 
442 


52 
35 


149 
101 


91 
94 


57 
61 


42 

48 


391 
339 


59 
92 


6 

11 


1899 


Males 
Females 


518 
544 


62 
52 


133 

149 


107 
112 


88 
86 


45 
59 


435 

458 


76 

78 


7 
8 


1900 


Males 
Females 


647 

589 


72 
64 


147 
108 


116 
115 


119 

89 


62 

75 


516 
451 


114 
126 


17 
12 


1901 


Males 
Females 


606 

598 


64 

77 


172 
123 


122 
129 


102 
90 


51 
64 


511 
483 


89 
99 


6 
16 



JMIMITIIKIUA. 



541 



Table No. 73. — Per Cent, of Mortality from Diphtheria in Different cities of (he 

I 'nihil States. 



Cities. 


Treatment. 


L895. 


1896. 


lxi7. 


1898. 


1899. 


1900. 


1901 


1902. 


Baltimore, Mil. 


No antitoxin . 
With antitoxin 








19.83 
9.8 


17.52 

9.8 


15.01 

9.8 


14.62 
8.3 


13.37 


Baltimore, Md. 


' 




6.87 


Lowell, Mass. 
Lowell, Mass. 


No antitoxin . 
With antitoxin 


48.0 
28.0 


56.0 
10.0 


27.0 
9.0 


35.0 

9.0 


39.0 
12.0 


30.0 
40 


30.0 
11.0 


26.0 
8.0 


Newark, N. J. 
Newark, N. J. 


No antitoxin . 
With antitoxin 


23.0 
13.0 


31.0 

11.0 


19.0 
11.0 


17.5 
10.5 


14.5 

8.77 


14.6 

8.1 


22.7 
6.6 


19.0 
70 


Rochester, N.Y. 
Rochester, N.Y. 


No antitoxin . 
"With antitoxin 




22.7 

12^24 


21.7 
9.6 


23.9 
9.0 


17.5 
9.7 


18.7 
6.5 


8.9 

8.4 


10.96 
6.97 






Bacteriology. — In the year 1883 bacilli, which were very peculiar 
and striking in appearance, were shown by Ivlebs to be of con- 
stant occurrence in the pseudo-membranes from the throats of those 
dying of true epidemic diphtheria. One year later Loeffler pub- 
lished the results of a very thorough and extensive series of investiga- 
tions on this subject. He found the bacillus described by Klebs in most 
but not all cases of throat inflammations which had been diagnosticated as 
diphtheria. He separated these bacilli from the other bacteria present 
and obtained them in pure culture. When he inoculated these bacilli upon 
the abraded mucous membrane of susceptible animals, pseudo-membranes 
were produced, and frequently death followed. If a certain amount of a 
bouillon culture was injected subcutaneously into guinea pigs, death was 
caused with characteristic lesions. Loeffler's failure to find the bacilli in 
every case examined is now explained by the fact that certain varieties of 
pseudo-membranous inflammation not due to the diphtheria bacillus, such 
as occur especially in scarlet fever, were then wrongly considered to be true 
diphtheria. 

"In 1887 further studies by Loeffler added to the proof of the depend- 
ence on the diphtheria bacilli. In 1888 D'Espine found the bacilli in 14 
cases of characteristic diphtheria, and proves them to be absent in 24 cases 
of mild sore throats, which, clinically, were believed not to be cases of diphr 
theria. In the same year the first portion of the results of the very impor- 
tant investigations of Eoux and Yersin was published, and the dependence 
of diphtheria bacilli may be considered to have been established. Eoux 
and Yersin found the diphtheria bacilli were present in all characteristic 
cases of diphtheria, and that these bacilli possessed the cultural and patho- 
genic qualities of those described by Loeffler. They found, too, when the 
bacilli were inoculated upon the healthy mucous membrane of the trachea 



542 THE INFECTIOUS DISEASES. 

of the rabbit, no result followed; but, if the inoculation was made on the 
abraded membrane, phenomena occurred, which strikingly resembled those 
present in membranous laryngitis in man, i.e., congestion of the mucous 
membrane, followed by the formation of the pseudo-membrane, oedematous 
swelling of the tissues and of the glands of the neck, dyspnoea, stridulous 
breathing and asphyxia. Injections of cultures beneath the skin of rabbits 
and guinea-pigs in sufficient quantity caused their death in from thirty-six 
hours to five days, the period varying in ratio to the susceptibility of the 
animal, and the number and violence of the bacteria introduced. The 
same result followed the injections of filtered cultures, showing the products 
formed by the growth of the bacilli were, by themselves, capable of causing 
the general lesions. 

"Koux and Yersin were also able to produce in animals characteristic 
diphtheria paralysis. They produced this in many cases where the inocu- 
lated animal did not succumb to a too rapid intoxication. Paralysis com- 
menced in a pigeon three weeks after the inoculation of the pharynx after 
all membrane had disappeared, and the animal seemed to have completely 
recovered. 

"In rabbits the paralysis usually commenced in the posterior extremi- 
ties and then gradually extended to the whole body, causing death by 
paralysis of the heart or respiration. In rare instances, the muscles of the 
neck or larynx were first paralyzed, and thus characteristic symptoms were 
caused. 

"The authors conclude : 'The occurrence of these paralyses, follow- 
ing the introduction of the bacilli of Klebs and Loeffler, completes the re- 
semblance of the experimental disease to the natural malady, and estab- 
lishes with certainty the specific rule of this bacillus/ 

"Finally, the microscopic changes in the internal organs of animals 
dying of experimental diphtheria produced by the bacilli have been shown 
by Welch and Flexner, and by Babes and others, to be essentially the same 
as those produced by diphtheria in man, and thus a still further proof is 
afforded of the specific rule of this bacillus." 

The reason for the various observations detailed above have since been 
confirmed by a great number of combined clinical and bacteriological in- 
vestigations, so that all who have studied the bacteriology of diphtheria 
would now agree with the following statement made by Welch in an ad- 
dress on diphtheria : "All the conditions have been fulfilled for diphtheria 
which are necessary to the most rigid proof of the dependence of an infec- 
tious disease upon a given micro-organism, viz. : the constant presence of 
this organism in the lesions of the disease, the isolation of the organ- 
ism in pure culture, the reproduction of the disease by inoculation of pure 
cultures, and similar distribution of the organism in the experimental and 
the natural disease. In view of these facts we must agree with Prudden 



DIPHTHERIA. 543 

thai we arc now justified in saying that the name diphtheria, or at leasl 
primary diphtheria, should be applied, and exclusively applied, to thai 
acute infectious disease usually associated with pseudo-membranous affec- 
tions of the mucous membrane which is primarily caused by the bacillus 
diphtherias of Loeffler." 

The germs cannot be found in the blood, but usually in the 
membranes. Now and then the specific germ may not be easily found 
in the pseudo-membranes. When such is the case, several cultures may be 
necessary to demonstrate the presence of the Klebs-Loeffler bacillus. This 
bacillus is most easily found in the older pseudo-membranes. 

Frequently we find the streptococcus or the staphylococcus accom- 
panying the Klebs-Loeffler bacillus. We are not justified in pronouncing 
the visible pseudo-membrane diphtheria unless we find the Klebs-Loeffler 
bacillus present. 

When there is a pseudo-membrane present and the Klebs-Loeffler ba- 
cillus cannot be found, then a provisional diagnosis of diphtheria can be 
made. 

Technical errors will sometimes occur in the taking of cultures or in 
inoculating culture media, Thus the germ may not be found. The rule 
always followed by the writer is to isolate every patient having visible mem- 
branes until the same have disappeared. 

The bacillus can frequently be "transmitted through animals. Cows, 
cats, dogs, and pigeons having diphtheria can easily infect those coming 
in contact with them. Cows' milk can transmit the disease if the Klebs- 
Loeffler bacillus exist therein. 

Characteristics of the Loeffler Bacillus. — The diameter of the bacilli 
varies from 0.3 to 0.8 micro-millimeters, and the length from 1.5 to 6.5 
micro-millimeters. They occur singly and in pairs, and very infrequently 
in chains of three or four. The rods are straight or slightly curved, and 
usually are not uniformly cylindrical throughout their entire length, but 
are swollen at the ends, or pointed at the ends and swollen in the middle 
portion. Even from the same culture different bacilli vary greatly in their 
shape and size. The two bacilli of a pair may lie with their long diameter 
in the same axis, or at an obtuse or an acute angle. The bacilli possess 
no spores, but have in them highly refractile bodies. They stain readily 
with the ordinary aniline dyes and retain their color after staining by 
Gram's method. With an alkaline solution of methylene blue, the bacilli, 
from blood serum especially, and from other media less constantly, stain in 
an irregular and extremely characteristic way, namely, club-shaped. 

The bacilli do not stain uniformly. Certain oval bodies situated in 
the ends, or in the central portions, stain much more intensely than the rest 
of the bacillus. Sometimes these highly stained bodies are thicker than the 
rest of the bacillus, again they are thinner and surrounded by a more slightly 



544 THE INFECTIOUS DISEASES. 

stained portion. The bacilli seem to stain in this peculiar way at a certain 
period in their growth, so that only a portion of the organisms taken from 
a culture at any one time will show the characteristic staining. In old 
cultures, it is often difficult to stain the bacilli, and the staining, when it 
does occur, is frequently not at all characteristic. 

Growth on Blood Serum. — If we examine the growth of the diph- 
theria bacillus in pure culture on blood serum, we will find at the end of 
ten to twelve hours little colonies of bacilli, which appear as pearl-gray or 
whitish-gray slightly raised points. The colonies when separated from each 
other may increase in forty-eight hours, so that the diameter may be 1 / 4 
inch. The borders are usually somewhat uneven. These colonies lying 
together fuse into one mass, especially if the serum is rather moist. During 




Fig. 164. — Diphtheria or Klebs-Loeffler bacilli; smear preparation from ton- 
sillar deposit. Loeffler's stain. X800. (Lenhartz-Brooks.) 



the first twelve hours, the colonies of the diphtheria bacilli are about equal 
in size with those of the streptococci; but after this time the diphtheria 
colonies become larger than those of the streptococci, nearly equaling those 
of the staphylococci. The diphtheria bacilli in their growth never liquefy 
the blood serum. 

The Relation Between the Length of the Bacillus and its Virulence. — 
Some investigators believed that the degree of virulence possessed by the 
diphtheria bacilli could, to a certain extent, be judged by their length. 
The longest bacilli were supposed to be the most virulent ; those of medium 
length less so, and the shortest, little if at all virulent. By observing 
this characteristic it was thought cultures might become helpful in 
prognosis. 



DIPHTHERIA. 



545 



"The short Klebs-Loeffler bacillus apparently produces a toxin of 
greater virulency than the larger forms, although the local manifestations 
ma\ not be so extensive. 1 



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Fig. 165. — True and False Diphtheria, fa,) Diphtheria bacilli xlOO 
diameter; (b) characteristic diphtheria bacilli xlOOO. (c) colonies of diph- 
theria bacilli xl24 diameters; (d) even-stained short diphtheria bacilli xlOOO; 
(e) pseudo-diphtheria bacilli XlOOO; (f) streptococci smeared directly upon 
cover glass from throat exudate XlOOO. (After Park.) 

"The long Klebs-Loeffler bacillus and the streptococci, when found 
alone, give rise to a mild type of the disease. 

"The streptococcus is found associated with Klebs-Lceffler bacillus in 

X X. J. Class (X. Y. Medical Journal, May 14, 1897). 



546 THE INFECTIOUS DISEASES. 

most severe cases. Its special significance is not so clear, but it is possible 
that by causing a more intense inflammatory reaction it opens avenues by 
which the toxins of the Klebs-Loeffler bacillus, plus its own toxin, may find 
more ready entrance into the circulation. 

"The apparent beneficial action of the antitoxin of the Klebs-Loeffler 
bacillus in cases where this bacillus is not present may be due to the fact that 
though the local action of the different microbes varies to a considerable ex- 
tent, the action of their toxins, as is shown by the similarity of the constitu- 
tional symptoms produced by them, presents many kindred features. The 
thought therefore arises that the antitoxin of one infection may have an in- 
hibitory effect on the toxin of another as is shown by the fact that whooping- 
cough and some other infectious diseases have been shown to occur less fre- 
quently in vaccinated persons, and some cases have apparently been cured 
by vaccination. 

"By the term Klebs-Loeffler bacillus is meant the medium-sized bacillus 
as described by Martin/' 

Very careful notes have been made on this point in the examination of 
the bacteria from the original serum tubes in 1613 cases. 

The results of the examinations are shown in the following table: — 

Table Xo. 74. 

Xo. of Cases. Mortality. 



Bacilli of average size f onnd in 

Bacilli longer than average in ... 

Bacilli shorter than average in . 

Bacilli short, not characteristic in shape and evenly stained, 
of which many were psendo-diphtheria bacilli ... 



1398 


■26 


per 


cent. 


B2 


07 


per 


cent. 


67 


85 


per 


cent. 


66 


12 


per 


cent. 



ZSTnmber of cases examined 1613 

"The results obtained from this examination of 1613 cultures, therefore, 
indicate that in Xew York the great majority ui cases of diphtheria yield in 
cultures, bacilli of medium size, which are characteristic in shape and man- 
ner of staining. In a moderate number of cases the bacilli found are much 
longer, and in about an equal number they are much shorter. Both the 
clinical histories and the animal experiments show that whenever in their 
shape and in the way in which they take the staining fluid the bacilli are 
characteristic, no information as to their virulence, either in men or ani- 
mals, can be gathered from their length. Those bacilli, on the other hand, 
which are short and stain uniformly with methylene blue, usually prove to 
be of the pseudo-diphtheria type, and have no virulence in animals.' 7 

Pathology. — The pathological lesions are caused by the specific action 
of the Klebs-Loeffler bacillus and the associated pathogenic bacteria. In 



Dli'HTHKRIA. 



54 







Fig. 166. — Section from an inflamed uvula covered with a stratified 
fibrinous membrane, from a case of diphtheritic croup of the pharyngeal 
organs (Miillers fluid, hematoxylin, eosini. (a) Surface layer of coagulum. 
consisting of epithelial plates and fibrin and containing numerous colonies 
of coco: - ond layer of coagulum, consisting of fine-meshed fibrin net- 

work enclosing leucocytes ; | e) third layer of coagulum, lying upon the con- 
nective tissue, and consisting of a wide meshed reticulum of fibrin enclosing 
leucocytes: fdj connective tissue infiltrated with cells: (e) infiltrated bound- 
ary layer of the connective tissue of the mucous membrane: ff / heaps of red 
blood-cells: (g) widely dilated blood-vessels: fh) dilated lymph-vessels filled 
with fluid, fibrin, and leucocytes: ft) duct of a mucous gland distended with 
secret: -ection of a gland: (1) fibrin reticulum in the super- 

ficial layer of connective tissue. X45. (Ziegl- 



548 



THE INFECTIOUS DISEASES. 



addition thereto the toxins generated by the various micro-organisms pro- 
duce local destructive changes. 

As a rule, the local pathological lesion is a whitish, yellowish-white, 
or grayish-white membrane, which is firmly adherent. In some instances 
a distinct greenish or black color (gangrenous type) is evident. 

In a study of the pathology of 220 fatal cases of diphtheria by Mal- 
lory, Councilman, and Pearce they found two varieties of membrane; first, 
a dense, firm, elastic membrane composed of a reticular structure with 
considerable uniformity in the size of the beams composing it. This mem- 
brane can be stripped off in large flakes. Second, a more friable variety 
composed of fibrin forming a reticulum with more irregular spaces and 
fibers. The fibrin spaces contain leucocytes, amongst which are found some 
broken clown cells (detritus). The epithelium below the membrane con- 
tains polynuelear leucocytes and lymphocytes. 

The interval lesions of diphtheria are those resulting from degenerative 
changes affecting organic structures. As a rule, haemorrhages are found in 
addition to marked degeneration. The lymph nodes are usually swollen 
and contain small foci of cell-necrosis. Broncho-pneumonia, if present, 
shows the usual lesions common to this condition. The nervous system, 
heart, spleen, lungs, and liver show the most destructive effect of the toxins 
of diphtheria. 

Table No. 75. — Two hundred and nine cases of Diphtheria studied by Councilman, Jfallory, 

and Pearce, of Boston, in 1901, skewing the percentage of cases in which 

the different bacteria were found by culture. 





Heart's Blood. 


Liver. 


Spleen. 


Kidneys. 


Diphtheria Bacillus ... 
Streptococcus ......... 

Staphylococcus Aureus . 
Pneumococcus . . .... 


6 per cent 
20 " 
2.5 " 
1.5 " 


20 per cent. 
30 

4 " 

2.5 " 


12 per cent. 
27 " 

3 

1.5 " 


19 percent. 
28 

8 " 

5 " 



The Blood.— John S. Billings, Jr., 1 says :— 

1. The red corpuscles of the blood in diphtheria undergo a diminu- 
tion in number in cases of moderate severity and in severe cases. Eegen- 
eration is slow. 

2. The leucocytes are increased in numbers in all but two classes of 
cases, exceptionally mild cases and exceptionally severe ones. As a rule, 
the amount of leucocytosis is directly proportionate to the degree of severity 
of the case. The leucocyte-curve shows no correspondence to the clinical 
course of the disease. The number of leucocytes often remains higher than 
normal for days after all inflammation has disappeared. The leucocytosis 
is similar in character to that seen in pneumonia and scarlet fever, the 
increase of the leucocytes being in the so-called polynuelear forms. 



'•Annual Report, Health Department, 1897. 



DIPHTHERIA. 549 

3. The percentage of haemoglobin falls eoincidently with the number 
o( the red blood-corpuscles, and to the same relative degree. But the 
regeneration of the haemoglobin takes place much more slowly than that 
of the red blood-corpuscles. 

4. In cases treated with antitoxin the diminution in the number of 
the red corpuscles is much less marked than in those cases treated without 
it; in a majority of cases no such diminution takes place. The leucocytes 
are apparently unaffected by the antitoxin. The haemoglobin is also much 
less affected in the cases treated with antitoxin, thus confirming the state- 
ment as to the red corpuscles. 

5. In healthy individuals injected with antitoxin, the red corpuscles 
show a very moderate reduction in number in about one-half the cases. 
The haemoglobin is correspondingly affected. The leucocytes are apparently 
unaffected by the injections. 

6. Xo peculiar characteristic changes in the morphology of the cor- 
puscles were to be made out. 

7. It is improbable that any information of prognostic importance is 
to be gained by the examination of blood in diphtheria. 

8. The antitoxin treatment of diphtheria has no deleterious effects 
upon the blood-corpuscles. On the contrary, it seems to prevent degenera- 
tive changes which would otherwise be brought about. 

The Effect of Diphtheria Toxin on the Nervous System. — E. Luisada 
and D. Pacchioni 1 report the results of a number of experiments with diph- 
theria toxin on dogs : — 

1. The diphtheria toxins applied directly to the nervous system pro- 
voke a profound lesion at the point of application, characterized by an 
inflammatory and degenerative action. 

2. These lesions are propagated more or less extensively from the 
point of application. 

3. In non-immunized dogs, which had been injected with a dose suffi- 
ciently toxic, the phenomena of local reaction were noted. 

4. In immunized dogs the toxins constantly produced alterations in 
the central nervous system, intense, localized, but of less extent than those 
produced in dogs non-immunized. 

5. The toxin applied directly to the medulla is propagated rapidly in 
all directions, preferring the posterior columns, the gray matter, and the 
central canal, as routes. In consequence of ~ the bulbar invasion death 
occurred in the animals more rapidly when the toxins were introduced into 
the medulla than when applied to any other portion of the cerebro-spinal 
axis. "When the toxins were introduced into the cerebral cortex, character- 
istic lesions of these regions were manifested. Death occurred later through 
propagation of the poison to the medulla. 

1 Giornale della R. Accademia di Medicina di Torino, vol. hri. 



550 THE INFECTIOUS DISEASES. 

6. Toxins introduced into the sheath of the sciatic nerve provoked an 
inflammatory process more or less intense, but more circumscribed than in 
the central nervous system. From the nerves the poison ascended to the 
medulla, chiefly through the posterior columns, and thus provoked an as- 
cending myelitis. 

7. The lesions produced upon the neuroglia by direct action of the toxins 
are similar to those reported by Vassale, Donaggio, and others in the various 
intoxications and infective processes. In the oblongata the prevalent alter- 
ations are found in the crossed pyramidal tracts and posterior columns. 

8. The alterations produced by the toxins affect the nerve fibers more 
than any other part of the nervous tissue. These lesions affect principally 
the myelin, and consist of a physical modification of it, whereby the con- 
nections between the various nerves are lost. There is partially a chemical 
modification of the myelin also present. 

9. The local action of the toxins has much importance in the genesis 
of various paralyses as seen in the human family, attacking first the sheaths 
of the nerves, then the nerves, and later the nerve centers of the medulla. 

Action of Diphtheria Poison on the Heart. — F. Roily, first as- 
sistant to the children's clinic at Heidelberg, as the result of a series of 
experiments on animals with the diphtheria toxin, 1 concludes that: — 

1. The fall in blood-pressure induced by the poison of diphtheria is 
due to paralysis of the vasomotor center, and also to the paralysis of the 
heart, which in spite of artificial respiration soon ceases to beat. 

2. This action on the heart is direct, and in warm-blooded animals is 
independent of the nervous system. 

3. The paralysis of the heart develops after a more or less definite 
latent period. Direct injection of the diphtherial poison or transfusion of 
lethal diphtherial blood interferes with the action of the isolated normal 
rabbit's heart only after a certain latent period. 

4. On the other hand, the action of the poison takes place at the same 
time, even if, before the appearance of poisonous symptoms or at the be- 
ginning of such toxic action, the heart is washed out with normal blood. 

5. This property possessed by the diphtheria poison of action on the 
heart leads to the opinion that the poison gradually takes hold of the heart 
muscles, and is seemingly stored up there until its complete action is mani- 
fest; this further explains the continuance of functional heart disturbances 
after many of the acute infections. 

Symptoms and Course. — Considering the clinical picture of this dis- 
ease, the following classification would appear most plausible: — 

1. Local diphtheria (mild). 

2. Diphtheria with constitutional symptoms (severe). 

3. Septic diphtheria (usually fatal). 

1 "Archiv fur experimentelle Pathologie u. Pharmakologie," 42, 1899. 



D1IMIT1IKRIA. 551 

Local diphtheria usually commences with symptoms of malaise. The 
appetite is poor; the tongue is coated, and the lymph glands at both sides 
of the jaw are swollen. The pharynx is reddened. The mucous membrane 
is swollen and the tonsils are covered with small, grayish yellow plaques, 
which adhere very firmly. On attempting to remove a piece of membrane 
a bleeding surface remains. This membrane peels off gradually, but leaves 
a red line of demarcation on the tonsils. A close study of the tonsil will 
show the former size of this pseudo-membrane. Usually the color of the 
pharynx returns to normal; sometimes it is rather anaemic, and after a 
few days the scar will show the presence of the former affection. When, 
however, this condition does not resolve in a few days, then there is always 
danger of a systemic infection. A small apparently innocent patch on 
the tonsil or pharynx should he as vigorously treated as a general septic 
infection. In other words the danger of a small patch extending to the 
larynx should not be forgotten. Other forms of local affections are: 
Sometimes the lips or the nose, the mucous membrane of the mouth, 
the tongue, the vagina, or the skin are the seat of a diphtheritic infection. 
Not infrequently diphtheria affects the umbilicus. Such diphtheritic 
omphalitis is exceedingly dangerous and frequently fatal. Rhinitis, espe- 
cially in young infants, is frequently a diphtheritic process, although re- 
sembling an ordinary "cold in the head." The sudden appearance of croup 
will frequently cause a fatal termination if neglected. 

Diphtheria vjith Constitutional Symptoms. — This condition usually 
commences with fever. The temperature varies between 101° to 102° 
F. If children are old enough they will complain of chills. It is not 
uncommon to have convulsions. The cheeks are usually flushed, in some 
instances they are very pale. The mucous membrane of the mouth is red- 
dened. The pharynx has a dark red color. The tonsils are swollen. Both 
tonsils are intensely congested and covered with a yellowish or yellowish- 
gray membrane. The uvula is usually involved. There is pain on swallowing 
and a decided nasal tone of voice. The submaxillary glands are swollen. 
The nose discharges an acrid fluid containing yellowish shreds or flakes. In 
many cases after careful treatment the appetite returns. The diphtheritic 
patches are limited in area. The intense swelling and congestion fades. 
The mucous membrane appears and the swelling of the submaxillary glands 
subsides, so that conditions resume their normal state. On the other hand 
the affection may spread from the pharynx and involve the velum palatinum 
and extend downward so that the larynx is involved, causing stenosis and 
other serious symptoms. 

Nasal Diphtheria. — When the local affection is confined to the nose, 
the outlook is not good. It is important to remember that no form of 
diphtheria is more fatal than the nasal variety. 



oo: 



THE ESTECTIOUS DISEASES, 



When there is a general infection, then greater attention should be 
paid to the condition of the heart. The pulse is usually small and thready. 
The heart sounds are feeble; sometimes they are muffled. In other in- 
stances there is a tachycardia. The extremities are usually cold. If these 
symptoms do not subside, and the affection spreads, then there may be later 
a total absence of the patellar reflexes. There may also be vo mitin g, a 
decided apathetic condition, and a slowing of the heart's action (brady- 
cardia) . 



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Fig 167. — 3ase rf Nasal Diphtheria. George P. Willard Parker Hos- 
pitaL Injected with 3000 units of antitoxin, on the 15th, and 5000 on :he 
17th. (OriginaL) 

rge P.. — age " . yea rs, admitted to the Wiliard Parker Hospital Oct. 15; ill 
two day*. General condition, fair. Xo psendo-membrane was risible in the throat. 
The cervical glands were veiy much enlarged. There was a serosanguineons discharge 
from the nose: besides, the entrance to the nostrils appeared angry and excoriated* 
Bacteriological examination showed rHebs-Loeffler bacilli Patient was allowed out 
of bed October 22. 



The liver is nsnally very mnch enlarged and feels very hard on palpa- 
tion. In other cases there will be marked diminution in the quantity of 
urine. . When urine is scanty and contains casts and blood, showing a dif-« 
fuse nephritis, then it is not rare to find convulsions of a ureemic character^ 



DIPHT1IKKIA. 



553 



resulting fatally. The sudden appearance of diarrhoea is frequently a very 
serious symptom, resulting in collapse and ending fatally. 

In other instances continuous crying may he the forerunner of earache 
resulting in suppuration. Not infrequently moist rales and bronchial 
breathing show evidences of broncho-pneumonic areas in the lungs, so that 
the general infection o\' a child with diphtheria should be dreaded, owing to 
the danger of complications associating themselves with the primary con- 
dition. 

Septic Diphtheria. — Frequently a pharyngeal affection in septic 
diphtheria will assume a decided gangrenous character. If this gangren- 



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Fig. 168. — Septic Type of Diphtheria Complicated by Myocarditis. 
The effect of the poison is shown on the heart. Xote the pulse-rate, low 
temperature and the respiration. (Original.) 

ous state appears, we will find the pharynx to he the seat of a putrid, 
smeary exudate covering the tonsils and the velum palatinum. From 
the nose a sanious, foul-smelling discharge exudes. The lips appear chapped 
and bloody. The tongue is shining and dry. The submaxillary glands are 
very much swollen. The children appear puffed, and the face has a pale, 
waxy appearance. The extremities are cool. The heart sounds are weak, 
sometimes inaudible. The pulse is small, sometimes thready, and can be 
counted with difficulty. There is severe constipation, rarely diarrhoea. 
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dition, moaning and with mouth open. The urine is diminished and con- 



554 



THE INFECTIOUS DISEASES. 



tains albumin and also epithelium. There is a general apathetic condition, 
and the cardiac weakness increases until the fatal termination. In other 
instances there is a decided hemorrhagic tendency. Hemorrhagic spots 
appear on the skin. The urine is bloody. The stools contain blood. 

Epistaxis is frequent. There is a general somnolence. A tendency to 
collapse, ending fatally. 



Follicular Forms of Diphtheria. 

"We are frequently called to see children having follicular tonsillitis. 
Such children should be isolated, and treated as though we were dealing 
with true diphtheria. Every follicular inflammation in the tousil should 
be looked upon with suspicion. It is necessary to take a culture to see if 



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Fig. 169. — Broncho-pneumonia Complicating Diphtheria. Antitoxin 
rash scarlatinal in character appeared four days after injection. Second 
eruption appeared ten days later. Note peculiarity of temperature curve. 
Severe croup required intubation. Child remained well for thirty-two days 
after second intubation, then severe croup appeared and required intubation. 
In all seven intubations were required. Child discharged cured. (Original.) 

the Klebs-Loeffler bacilli are present. It is well to remember that diph- 
theria frequently manifests itself in the form of a follicular infection in 
which the disease is confined to the lacunae of the tonsil. (See colored 
illustration.) 

When the disease is confined to the crypts or follicles of the tonsils, 
then, clinically, this diphtheritic infection resembles that form of non- 
diphtheritic tonsillitis which is commonly called quinsy. 



PLATE XV 

Case A. — Common Type of Diphtheria. Child three years old. Seen 
on fourth day of illness at the Willard Parker Hospital. Exudate covering 
tonsils, pharynx, and uvula. Received in all 16,000 units of antitoxin. 
Throat clear on sixth day. Case discharged cured. (Original.) 



Case B. — Follicular Type of Diphtheria. Child seven years old. 
Seen on second day of illness at the Willard Parker Hospital. The mem- 
brane involved the lacunae of the tonsils. Note the close resemblance to 
follicular tonsillitis. Received in all 6,000 units of antitoxin. (Original.) 



Case C. — Hemorrhagic Type of Diphtheria. Child seven and one- 
half years old. Seen on sixth day of illness at the Willard Parker Hospital. 
Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal 
haemorrhages during exfoliation of membrane. Received in all 15,000 units 
of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. 
Case discharged cured four weeks after admission. (Original.) 



Case D. — Septic Type of Diphtheria. Child eight years old. Seen 
on the fifth day of illness at the Willard Parker Hospital. The pseudo- 
membrane in this case covered the hard palate and extended in one large 
mass down the pharynx, completely hiding the tonsils. (Original.) 



PLATE XV 






\ 


j 




^ftf* 












mm! 


I /ll 


I. V 


§ i 


J ^J^W ¥ 


. 


W0 J 





DIIMITIIKKIA. 



555 



Whether diphtheria affects the pharynx, the larynx, or the crypts of 

the ton>il>, the disease is diphtheria, am! the treatment should be aimed 
at limiting the disease to prevent toxaemic conditions and complications. 

Rashes. — Very frequently rashes follow the injection of antitoxin. 
These rashes are o\' an erythematous character: — 

(a) Scarlatiniform. (b) Morbilliform. (c) Urticarial. 

In a report made by the Investigating Committee of the Clinical 
Society of London, of 6o'S cases, there were rashes in 220, or 34.7 
per cent. Of these the rash was : — 

Erythematous 1G1 

Urticarial 37 

Mixed 17 

Petechial 5 

The following series of cases were noted by Dr. Burckhalter at the 
Willard Parker Hospital during my service: — 

Table No. 76. 



April, 1903 



May, 1903 



Total Cases 
Died 
Discharged . 



117 Total Cases 
29 I Died . 

Discharged 



June, 1903 



July, 1903 



130 I Total Cases 
29 I Died. . 
. 9 Discharged 



131 
25 
12 



Total Cases . 
Died . . 
Discharged 
Transf 'd * 
Tracheotomy . 



101 

17 

15 

2 

1 



Total Tube Cases, 35 Total Tube Cases, 38 Total Tube Cases, 37 Total Tube Cases, 34 



Xo. of 
Rashes. 



Days After 
Injection. 



4 
5 
6 
7 
8 

10 
12 
18 
19 
26 



32 Rashes 



Largest Number, 
each on 2d and 3d Days 



No. of 


Davs Af er 


Rashes. 1 Injection. 


6 


2 


11 


3 


5 


4 


4 


5 


2 


6 




7 




8 




10 




11 




12 




14 




15 




19 




26 


38 Rashes 


Largest Number, 


lion 


3d Day 



No. of 



18 

10 
3 
4 

1 
1 
2 
2 



Days After 
Injection. 



41 Rashes 



Largest Number, 
18 on 2d Day 



No, of 
Rashes. 



Days After 
Injection. 



20minutes 

6 hours 

2 day* 

3 

4 

5 

6 

8 

9 
10 



34 Rashes 



Largest Number, 
10 on 2d Dav 



Total Number of Cases, 479. Total Rashes, 145: 



1 Transferred to Riverside Hospital, New York. 



556 THE INFECTIOUS DISEASES. 

C. Hartung quotes a number of European observers who found an 
antitoxin rash in 11.4 per cent, out of 2661 cases. Berg found the rash 
in 82 cases out of 337 or 24 per cent. This condition is described in detaL 
in Nothnagers Encyclopaedia, pages 153-162. 

While Northrup reports 147 cases of rash occurring between the seventh 
and twelfth day, other observers report the rash as occurring much earlier. 
In the series above reported the largest number of rashes occurred on the 
second and third day after the injection. I have frequently seen an anti- 
toxin rash several hours after the injection was given, while the majority 
of rashes were fully developed on the second day. 

The following case illustrates the rapidity with which a rash may 
appear : — 

Laurence S., aged 4 years. Admitted September 8, 1903, to the Willard Parker 
Hospital, on the third day of illness. He was in a poor condition when admitted. 
He was intubated about one-half hour before being admitted to the hospital. Slight 
retraction present. Membranes on right tonsil. Profuse nasal discharge. 

The physical examination was negative. The heart regular and of good force; 
4000 units of antitoxin, of serum (horse) 220, were given when admitted. There was 
no rash present when the antitoxin was injected. Seven minutes after the antitoxin 
injection the patient had a profuse rash all over the chest, extending from the fifth 
ribs to clavicles. The rash and flush were most marked in the area corresponding 
to the place of injection. The tongue was heavily coated. Could not take much 
nourishment. Grew gradually worse. Died September 9th. 

Site of the Eruption. — A large flush is frequently seen on the parts 
around the point of injection, from whence it spreads over the body. It is 
most frequently seen, however, on the abdomen, chest, and buttocks; less 
frequently at the wrists, knees, and ankles. The face and neck are seldom 
involved. It sometimes covers the back as well as the buttocks. There is 
intense itching and occasionally the children complain of intense pain in 
the joints. 

Fever usually precedes the eruption. 

Constitutional symptoms, such as vomiting, diarrhoea, headache, mus- 
cular pains, and general malaise are noted. Not infrequently when hyper- 
pyrexia exists there is delirium or convulsions (Sevestre and Martin). 

Desquamation. — A very fine mealy desquamation follows the anti- 
toxin rash. It is similar to the measles desquamation (Berg). A rash re- 
sembling measles never has the catarrhal symptoms which we always note 
in genuine measles. If, however, we are in doubt regarding the true nature 
of the rash, it is well to isolate and await results rather than to expose 
children to the risk of infection. 

Diagnosis. — The diagnosis of diphtheria affecting the pharynx, ton- 
sils, and nares with visible membranes is quite easily made. When, how- 
ever, the disease affects the lower respiratory tract, the larynx, trachea, or 
bronchi, the diagnosis will be rendered more difficult. The crucial test con- 



TLATK XVI 




Lizzie F„ 5 years old. was admitted to the Millard Parker Hospital in 
September. 1904. She was ill seven days before admission. Diphtheria was 
present on both tonsils. There was slight glandular swelling. The general 
stemie condition was poor. The temperature was 101 r F„ pulse 126. 
respiration 24. The ehild recerred §000 units of antitoxin on admission, 
and on the following- day a second injection of 4000 units. Four days after 
the second injection of antitoxin, the throat cleared so that no membrane 
was risible. Two days later, or six days after the second antitoxin injec- 
tion- a unhersal rash appeared on the face, chest, abdomen, back, and ex- 
tremities. This rash was morbilliform in character and persisted for 
twenty-two day=. although it was chiefly confined to the arms and legs. Xo 
complication^ followed. The child left the hospital in excellent condition. 



DIPHTHERIA. 557 

sists in taking a culture and noting the bacteriological result. The presence 
of the Klebs-Loeffler bacillus means diphtheria. 

We must not infer that if the Klebs-Loeffler bacillus is not found thai 
our case is of a Don-diphtheritic character. A technical error, such as 
swabbing a healthy surface instead of an infected area, may be the cause of 
B negative result. Not infrequently in the most malignant forms of diph- 
theria, nothing but a streptococcus can be found. This is especially true 
when complications such as broncho-pneumonia are met with. 

Bacteriological Diagnosis. — Directions for Inoculating Culture Tubes 
with the Exudate in Cases of Suspected Diphtheria: The child should be 
placed in a good light, and properly held. Remove the swab from its tube. 
Depress the tongue with a spoon in the loft hand. With the swab in the 
right hand rub firmly but gently against any visible membrane on the ton- 
sils or in the pharynx. Withdraw- the cotton plug from the culture tube. 
Insert the swab, and rub it thoroughly but gently back and forth over the 
entire surface of the blood serum. Do not allow the swab to touch any- 
thing except the throat of the patient and the surface of the serum. Do 
not push the swab into the serum or break the surface in any way. Re- 
place the swab in its own tube ; plug both tubes ; fill out the blank forms 
which accompany each tube, and send to a culture station. 1 

If there is no visible membrane (it may be present in the nose or 
pharynx) the swab should be thoroughly rubbed over the mucous membrane 
of the pharynx and tonsils, and in nasal cases, when possible, a culture 
should also be made from the nose. In little children care should be taken 
not to use the swab when the throat contains food or vomited matter, as then 
the bacterial examination is rendered more difficult. Under no considera- 
tion should any attempt be made to collect the material shortly after the 
application of disinfectants (especially solutions of corrosive sublimate) to 
the throat. If any of these instructions have not been carried out the fact 
should be carefully noted on the record blank. 

Welch says : "The mere presence of the diphtheria bacilli in the throat 
of a patient no more proves that he has diphtheria then the presence of the 
pneumococcus in his saliva establishes the fact that he has pneumonia. The 
only decisive method, as claimed with much justice by Runge, is control 
experiments in the way of animal inoculations/' 

If a croupy cough is heard and associated with it a small diphtheritic 
membrane is seen on the tonsils, pharynx, or in the nose, the diagnosis of 
diphtheria can positively be made. 



1 The New York Department of Health has a series of culture stations in 
various drug stores. At these stations sterile culture tubes are supplied to the 
physician and the same are also collected daily after inoculation. The Depart- 
ment of Health furnishes material, including examination and report, free of charge. 



558 THE INFECTIOUS DISEASES. 

Differential Diagnosis. — In the very beginning of the disease, before 
the appearance of a pseudo-membrane, the diagnosis is beset with difficulty. 
Thus, an acute catarrhal angina will show symptoms similar to those of 
diphtheria. 

P re-membranous Stage. — If seen early the throat is usually intensely 
congested and reddened. It may be a day or two before the membrane will 
be visible. The disease is, primarily, a local disease. The systemic infec- 
tion which accompanies the same is due to the absorption of the toxins 
thrown out by the micro-organisms present in these pseudo-membranes. 

Thrush sometimes resembles diphtheria, but can be differentiated by 
the fact that the small whitish spots resembling curdled milk are scattered 
over the cheeks, lips, tongue, and gums, in addition to the uvula and 
pharynx. 

Ulcerative tonsillitis 1 resembling diphtheria has been described by Vin- 
cent. In this condition there is no tendency to spread. There is an absence 
of croup, and a culture taken shows the Vincent bacillus instead of the 
Klebs-Loeffler bacillus. 

Peritonsillar Abscess. — In this condition we meet with a swelling or 
bulging forward of the affected parts. The uvula is sometimes displaced. 
There are very many active local symptoms, such as pain and difficulty 
in swallowing, and a nasal tone of voice. Not infrequently when an at- 
tempt to swallow is made the fluid regurgitates through the nose. When 
children are old enough to describe subjective symptoms, they will complain 
of chills and fever. The temperature is usually high, ranging from 102° to 
105° F. The active symptoms subside the moment pus is relieved. Nature 
frequently gives a spontaneous evacuation of the pus. At other times it is 
wiser to give relief by making an incision and emptying the pus. A culture 
taken in this condition does not show the presence of the Klebs-Loeffler 
bacillus. 

Follicular Tonsillitis. — In this condition more than in any other form 
of disease we must be careful regarding a positive opinion. There are 
follicular forms of diphtheria involving the lacunar of the tonsils which 
clinically so resemble diphtheria that even an expert cannot differentiate 
them. 

The clinical manifestations of the benign form of follicular tonsillitis 
have already been described in the article on "Follicular Tonsillitis." 

The differential diagnosis depends on the presence or absence of the 
Klebs-Loeffler bacillus. 

Complications. 2 — The most frequent complication met with is broncho- 
pneumonia. More deaths occur from this than from any other complica- 



1 Read article on "Tonsillitis." 

2 For a detailed description of the various complications, the reader is referred 
to the special chapters on "Otitis/' "Empyema," etc. 



])1 I'll 1IIKRTA. 



559 



tion. It is usually the extension of the disease from the larynx to the 
bronchi. When a septic form of diphtheria exists broncho-pneumonia usu- 
ally accompanies it. (See chapter on "Pneumonia."') 

Pleurisy with serous effusion frequently complicates this disease. 

Empyema not infrequently complicates. A number of these cases have 
been seen by me during my service at the Willard Parker Hospital. 

Otitis is occasionally met with as a complication of diphtheria. It is 
usually the result of a streptococcus infection through the nose or throat 
into the Eustachian tube. 

Myocarditis is the most frequent form of heart complication met with 
in diphtheria. 

Endocarditis and pericarditis are also seen in severe types of this 
disease. 



\~s 




Fig. 170. — Pneumonia Complicating Diphtheria. (Kind assistance of 
Dr. Edward H. Sparkman, Jr., at the Willard Parker Hospital.) A. — Start- 
ing point of pneumonia showing extent on third day. B. — Focus which 
developed three days after (A) showing extent on third day of the new 
focus. (Original.) 



Meningitis is not often seen, though I have seen 3 such cases out of 
a total of 35 at the Willard Parker Hospital, during my service. About 
10 per cent, of all septic cases have meningitis. 

Cerebral thrombosis and embolism occasionally complicate diphtheria, 
and result in hemiplegia, convulsions, or aphasia. 

Thrombosis of the pulmonary artery of the heart may cause sudden 
death. This is usually accompanied by feeble heart's action, the result of 
degenerative changes in the muscular walls (Holt). 

Haemorrhages occur quite often. Bleeding from the nose and from the 
ear, also blood in the urine and blood in the stools has frequently been seen 
by me. These cases are of the most severe type and usually end fatally. 



560 



THE INFECTIOUS DISEASES. 



Purpuric spots similar to that form of purpura met with in rheumatism 
were seen by me in septic cases, all of which ended fatally. 

Nephritis 1 is usually met with in septic cases, although it may follow 
as a complication of the milder form of this disease. Traces of albumin 
are frequently found during the course of diphtheria. This does not 
necessarily imply that we are dealing with nephritis. The presence of casts 
iu addition to the albumin, or possibly blood, is necessary to strengthen the 
diagnosis of nephritis. 




Fig. 171. — Temperature Chart from a Case of Diphtheria complicated by 
Broncho-pneimionia (Step-ladder Type of Fever). (Original.) 



Diarrhoea due to a follicular ileo-colitis or acute gastric catarrh fre- 
quently complicates diphtheria. 

Diphtheritic Gastritis. — When membranous gastritis occurs it is usu- 
ally a diphtheritic gastritis. 

Diphtheritic omphalitis is described in Chapter III, Part II. 



1 An excellent illustration of nephritis complicating diphtheria is described in 
the article on "Nephritis." 



DIPHTHERIA. 



561 



When membranous enteritis complicates diphtheria it is usually the 
result of a streptococcus or Klebs-Loeiller infection. 

Profound anaemia usually follows diphtheria. This is due to the effect 
of the toxins in the blood causing the destruction of the red corpuscles. 

Postdiphtheritic Paralysis. — Toxaemia caused by absorption of the 
toxins generated by the Klebs-Loeiller bacillus, if not neutralized 
either by an injection of antitoxin or by Nature's own production 
of antitoxin, frequently causes paralysis. This paralysis usually 
affects individual muscles or groups of muscles. In this manner the 



i$.Q2... 


CTATES OF OBSERVATIONS" 




1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


a 


Cent. 


Fahr 


AM>M 


AM 


PM 


AMiPM 


am:pm 


AMiPM 


AM>M 


am:pm 


A&I-PM 


ktt'.m 


ANTPM 


ah:pm 


41°~ 
40°" 


- 
• 

: 106- 


9 
5 






• • 


• w: 


. 






* 








• 
• 

: 106° : 


3 -^ 

i « 




* 


V 








1 










- 
- 

104° • 


5 -^ 




/' 


J 


ii 






s 


: 






<^ 


39°~ 


■ 
: 103° : 


a 


/ 

f_ 


( 


• • 


\a 


t 


\; 


EJ 


■■A 


t 


^ 


OH 




• 








In 


4 


> 


\p 


/ 


i 


V. 




38°~ 


• 
■ 

-m°- 


! 
















v. 








- 
- 

100- 


i 

> 

* 
• 
























37°~ 


- 

- o* 

^99 ■ 


• 
• 
• 
























L 


• 
























36 °~ 


-9« •- 


























- • • 
r '< 

-97 • 


• 
• 
























- 
-96 • 


• 
• 
• 
























Pulu 
per minxUt 


1^ 
I" 4 


"31 


II 


m 


m 


3§ 


3§ 


5^ 






5 


Respiration* 

per minute 


IS 




ri Q 


-q «vj 






oJoc 


33 


"5k 


^2 


•3 



Fig. 172. — Temperature Chart from a Case of Diphtheria complicated by 
Lobar Pneumonia. (Original.) 



heart, which is a muscular organ, is frequently paralyzed, resulting 
in death. When the toxin affects the respiratory centers it may 
result in paralysis, causing death by asphyxia. In addition to the para- 
lytic effect of this toxin on the muscles and nerves, degenerative changes 
are brought about by the influence of this poison. Thus it is that the toxin 
in the system will frequently irritate an otherwise healthy kidney and set 
up a toxic nephritis. 



THE INFECTIOUS DISEASES. 



From the foregoing we can see that the poison generated by the Klebs- 
Loeffler bacillus is certainly a serious factor which must be dealt with very 
energetically. 

A study of recorded cases of paralysis shows that between 10 and 30 
per cent, of all cases of diphtheria are followed by paralysis. Woodward 
studied 7832 cases of diphtheria; of these 1362 had post-diphtheritic 
paralysis. Myers, in the London Lancet, 1900, studied 1316 cases of the 
disease, in which 275 cases, or about 21 per cent., had palsy. 
110 cases affected the palate, 
69 cases were cardiac, 
21 cases diaphragmatic. 

There are four palsies due to severe toxasmia ; they occur in the follow- 
ing order : palatal, ocular, cardiac, and diaphragmatic. 



I9Q3- 




JJu$USl 


4 


5 


6 


7 


8 


9 


10 


Cent. 


Fahr. 


AMIpM, 


am:pm 


am:pm 


am:pm 


AM>M 


AM.PM 


am:pn 


40°~ 


■i 

• i 

104° • ! 


• 
• 
• 


: 


* 


; 




t 


►,- 


39*" 
38°~ 


•1 

: 1Q3 : ! 


: 


\ 


/ 


\ 


\ 


/ 


\ 


•J 
•< 

- o*. 

102 'i 


• 
• 
* 


• 






\ 


/: 


• * 


•i 

•i 

101° : ! 








: 


; # 






•i 
•< 

100° -s 


• 
• 
• 














Pulse 
per minute 


he 


Q<2 


3! 


$$ 


3H 


Si? 




Respirations 
per minute 


1^ 




•q"» 











Fig. 173. — Temperature Chart from a Case of Diphtheria complicated by 
Otitis and Meningitis. Fatal. (Original.) 



Paralysis is most frequently found in children oetween the second and 
sixth years. Usually during the second week following diphtheria, when 
the child is convalescent, emaciation of the extremities will be noticed. If 
the muscles of the trunk are involved, there will be emaciation of the 
thoracic muscles, regurgitation of liquids through the nose, and a nasal 
twang in the voice. There is marked difficulty in walking or climbing 
stairs in other cases; the child waddles and appears weak, falls easily, and 
staggers as in ataxia. In severe cases the child is unable to raise its head. 
The sphincter of the rectum and bladder may become paralyzed, resulting 
in involuntary urination or obstinate constipation. 






DIPHTHERIA. 563 

Paralysis of the extremities may be added to paralysis of the respira- 
tory muscles or of the heart. The knee-jerk may be diminished or absent. 
The absence of the knee-jerk indicates some change in the peripheral neu- 
ron. The special heart symptoms indicating cardiac paralysis are irregu- 
larity of heart's action or a gallop rhythm, bradycardia, tachycardia, lower- 
ing of the temperature (usually subnormal), vomiting; dilatation of the 
heart, a short first sound with systolic murmur at apex, blueness of the lips, 
and cold extremities. 

"Monicatide divided diphtheritic paralysis into four groups: Thosfe 
showing (1) purely muscular change without nerve involvement; (2) 
polyneuritis; (3) lesions of the spinal cord, which were either localized in 
the gray matter, leading to atrophy of muscles, or involved the white matter 
of the cord in a similar w r ay to that seen in locomotor ataxia or multiple 
sclerosis, and (4) cerebral haemorrhage chiefly due to circulatory change. 
This classification is accepted by many of to-day. To be scientifically cor- 
rect, however, the fourth group, i.e., the cerebral palsies, should not be 
classed as a palsy due to a diphtheritic toxin, inasmuch as they are acci- 
dental. Strictly speaking the term diphtheritic palsy should be applied to 
those palsies only which are due to direct action of the diphtheritic toxin." 

A child, 4 years old, was seen during my service at the Willard Parker Hos- 
pital. He had suffered with severe tonsillar and pharyngeal diphtheria. The 
exudate was unusually thick. The resident physician called my attention to a 
regurgitation of the liquids through the nose and to the nasal twang in speaking. 
On examining the throat, all evidences of diphtheria had disappeared. The tip of 
the uvula, instead of hanging in the median line, pointed toward the left side. As 
this case was a severe type of diphtheria we were not surprised to see the paralysis. 
Strychnine was given. The case recovered. 

When diphtheria has preceded an attack of paralysis, the diagnosis 
is easily made. Emaciation is general as a rule and not confined to a sim- 
ple group of muscles. 

The disease is sometimes mistaken for acute anterior poliomyelitis. 
The onset of the latter is sudden and is usually preceded by fever. The 
absence of a history of diphtheria aids in establishing the diagnosis. 

In 275 cases reported by Myers, 80 died, or 29 per cent. 

Course. — A mild case of diphtheria will show exfoliation of the exudate 
on the tonsils and pharynx about twenty-four to forty-eight hours after a 
sufficient dose of antitoxin has been injected. In four or five days after the 
beginning of illness, the disease usually disappears, so that there is no 
visible evidence of the same. 

In a severe case 1 (male, 8 years old) seen by me in October, 1904, in the wards 
of the Willard Parker Hospital, the exudate completely covered the fauces. The 



1 The colored illustration D, Plate XV, was drawn from this case at the bed- 
side in the Willard Parker Hospital. 



564 THE INFECTIOUS DISEASES. 

tonsils, uvula, and pharynx were covered with one large ina*s of pseudo-membranes. 
The cervical glands were very much, enlarged. The case looked decidedly septic. 
An injection of 5000 units of antitoxin was given on the first day, soon after ad- 
mission to the hospital. A second injection of 5000 units was given on the second 
day. A third injection of 5000 units was given on the third day. A fourth 
injection of 5000 units was given on the fourth day, so that 20,000 units were admin- 
istered during the first four days after admission to the hospital. The membrane 
exfoliated, the swelling of the glands disappeared and one week after his admission, 
the throat was clear and he was convalescent. 2 

A mild case of diphtheria may last from five to eight days. Severe 
types may last many weeks. Xo ease of diphtheria should be considered 
to have run its course until the heart's action is normal and the general 
condition good. Sudden death may come from over-exciting a weakened 
or damaged heart if proper caution is not used. 

Prognosis. — The uncertainty of this disease and the ease with which 
complications follow must be taken into consideration in giving the prog- 
nosis in a given case of diphtheria. A child suffering from diphtheria, 
who was brought up in unsanitary surroundings or one deprived of breast- 
milk, will suffer much more than one favored with the opposite conditions. 
Such factors are important in giving an opinion. A child with rickets is 
more liable to succumb to an infection from diphtheria and may possibly 
die. when a child with a strong normal body and healthy internal organs 
will recover. In this disease we therefore note that it is the •'survival of 
the fittest.''" When diphtheria follows typhoid,, or when it is a complica- 
tion of a severe systemic infection, like scarlet fever, then great care should 
be exercised in venturing an opinion as to the probable outcome of the 
attack. 

The guide in estimating the prognosis of any case of diphtheria should 
always be the condition of the heart. A very rapid pulse or a gradually 
increasing pulse-rate are bad signs. The temperature cannot be looked 
upon as the most impotant factor in determining the outcome of this con- 
dition. I have seen cases of diphtheria in hospital as well as in private 
practice where normal temperatures prevailed and still septic conditions 
were positive. Such cases, showing a low inflammatory type having slight 
elevations of temperature, rarely recover. The prognosis is also influenced 
by the time at which the treatment was commenced. When antitoxin is 
injected on the first or second day of the disease the outcome is brighter 
naturally than when the disease extends without specific treatment. The 
mortality is greatest in children under 2 years of age. 

Prophylaxis. — In no disease should we be more careful than in diph- 
theria. Strict isolation of all cases should be enforced, so that no trans- 
mission of the disease can take place. Disinfection of infected clothing. 



2 This case was reported by me at a meeting of the 2Sew York State Medical 
Association held October 19. 1904. 






DIPHTHERIA. 5G5 

bedding, etc., should bo strictly carried out. Read article on "Disinfection," 
page 93 I. 

Visitors should never be permitted in a room where diphtheria exists. 

The vital point to be considered is how to prevent complications. The 
question arises: can complications be prevented by proper treatment? We 
certainly can if treatment is commenced early in the disease. We must 
carefully watch all the functions of the body and stimulate those that do 
not seem to act. The emunctories are the most important which require 
watching. If the kidneys are found secreting very small quantities of urine, 
then we can be reasonably sure that the toxins stored in the kidneys will 
cause serious damage. When therefore a scanty secretion of urine is met 
with it will at once call for active diuretic treatment. The rule I have 
always followed is to stimulate with mild diuretic treatment from the be- 
ginning, and secure a copious secretion of urine. The same is true regard- 
ing the condition of the bowels. In no disease is it as important to have 
food assimilated and to have proper evacuation as in the course of the 
treatment of diphtheria. 

We eliminate large quantities of toxins by the bowel, the skin, and 
the kidneys, hence we have it in our means to hasten recovery and at the 
same time we guard against storing up poison in the blood. 

The clothing should be warm. The child should not be exposed while 
bathing. We must guard against draughts, as we know there 
is a peculiar predilection for pneumonia in the course of diphtheria. The 
urine must frequently be examined. The examination must not only be 
chemical, but microscopical. The moment we find our case complicated 
by nephritis, the same should be given proper attention. 

Isolation. — Very frequently children have Klebs-Loeffler bacilli in the 
throat — so-called culture cases — in the pre-membranous stage of the dis- 
ease. Some of these develop diphtheria of the most virulent type. A safe 
rule therefore is to insist on the isolation of every child having the Klebs- 
Loeffler bacillus in the secretions of the nose and throat, for weeks and 
months if necessary, until a swab from the throat shows an absence of the 
Klebs-Loeffler bacillus, to guard against possible development of fatal diph- 
theria. 

The finding of diphtheria bacilli in the throat without marked clinical 
indications of diphtheria, has no significance, according to Behring. 1 

He asserts that about 10 per cent, of the entire population carry diph- 
theria bacilli in their throats without resulting infection. The bacilli have 
lost their virulence, or else the individual possesses a natural immunity. 
He considers all bacteria with the morphological characteristics of Loeffler's 
bacillus, true diphtheria bacilli, but he would differentiate a simple angina, 



Therapie der Gegenwart (Berlin). 



566 THE INFECTIOUS DISEASES. 

rhinitis, or conjunctivitis from diphtheria, even with diphtheria bacilli 
numerous in the organ involved, if there were no general symptoms of 
diphtheria. He affirms that it is useless and nonsensical to isolate persons 
who have been exposed to diphtheria. It is impossible to free people from 
the bacilli or to keep them permanently free. Infection results from a pre- 
disposition, which is in turn due to a lack of antitoxic serum in the blood. 
The antibodies which undoubtedly exist in the blood of numerous indi- 
viduals are probably produced by the vital activity of avirulent diphtheria 
bacilli in their throats. He consequently suggests that it might be possible 
to induce auto-immunization by transplanting avirulent diphtheria bacilli 
into the throats of other human beings. The comparative immunity of 
physicians to diphtheria may be due to the repeated, unconscious inocula- 
tion with small doses of the virus. Extensive, systematic preventive inocu- 
lation with antitoxin would induce a natural immunity to the disease and 
entail the final disappearance of diphtheria. 

While the view maintained by Behring is interesting, it certainly does 
not conform to modern clinical experience. No child should be permitted 
at large with diphtheria bacilli, owing to the possible fatal result entai]ed 
thereby. 

Immunization in Diphtheria. — Immunity in the Nursling: There 
seems to be an immunity conferred upon the nursling. This may be due 
to the anti-toxic properties of serum contained in the mother's milk. 

Diphtheria rarely attacks nurslings, but most frequently attacks infants 
brought up by hand-feeding — the bottle babies. It is most frequently met 
todth between the second and eighth years. The disease may recur and has 
been known to attack patients three or four and even more times. 

How to Immunize. — When a case of diphtheria occurs in a family in 
which there are apparently very healthy children, then immunity can be 
conferred upon them by giving an injection of antitoxin. This immunity 
is in the nature of prophylactic treatment. The average dose required for 
a child from 1 to 5 years is 300 to 400 units. For older children, from 5 
to 12 years, between 400 and 500 antitoxin units may be injected. No 
farther treatment will be necessary after the injection. All aseptic pre- 
cautions which are described in the chapter on the "Injection of Anti- 
toxin" must be used whether we inject a large or a small dose of anti- 
toxin. It must not be supposed that because an immunizing dose of anti- 
toxin has been injected, that such a child may then be exposed to this dis- 
ease with impunity. Experience has shown that when children have been 
given an immunizing dose of antitoxin and are immediately isolated, as a 
rule they do not take the disease. On the other hand, if children are per- 
mitted to remain in the same room with a case of malignant diphtheria, it 
is quite plausible to assume that they will take the disease, even though an 






DIPHTHERIA. 567 

immunizing dose of scrum has been injected. Immunity is usually con- 
ferred for a period of two or three weeks. It is a good plan to repeat this 
same immunizing dose of antitoxin if diphtheria still prevails in the house- 
hold three weeks after the first injection has been given. Children receiv- 
ing an immunizing dose should be treated as though they were perfectly 
well children. There should be no restriction to their diet and they should 
be permitted to romp and play in the open air, and receive their bath just 
as though no injection had been given. 

The Xew York Board of Health reported a series of immunizing in- 
jections in 6806 individuals, given by their inspectors from January 1, 
1895, to January 1, 1900. Out of the above number, 18 contracted diph- 
theria of a mild type; 1 contracted diphtheria complicated with scarlet 
fever; total, 19 cases; the last case of scarlet fever ending fatally. The 
Xew York Board of Health Division of Bacteriology, from January, 1898, 
to January, 1900, reports 682 cases of diphtheria which were secondary to an 
original case in the same family. Under secondary are included only those 
cases which occurred at least twenty-four hours after and within thirty 
days of the primary case. Of these 682 cases, 61 died, a mortality of 8.9 
per cent. Had these 682 cases received antitoxin (immunizing dose) when 
the physician first visited the families, probably not one of them would 
have contracted the disease. When immunity is conferred by an injection 
of antitoxin it lasts about twenty days, provided it is given twenty-four 
hours previous to actual exposure. 

As a rule no harm will result by the injection provided the serum used 
is of a standard quality. We must not expect to prevent follicular tonsil- 
litis or any other disease by an immunizing injection of antitoxin. 

Morrill reports that of 1808 children immunized at least every twenty- 
eight days with 150 to 500 units of serum, 7 had diphtheria; 3 from in- 
sufficient dosing, 2 within twenty-four hours of the injection, and 2 in 
twenty-two and twenty-three days. Of 829 who had not been given anti- 
toxin, or in whom more than twenty-eight days elapsed after the injection, 
9 had diphtheria, besides 3 immunized adults. 

Biggs and G-uerard, from 35 reports of 17,516 cases in which small 
doses of antitoxin were given as an immunizing agent, state that diphtheria 
occurred in 131 cases; 109 mild cases and 1 fatal case within thirty days 
of the date of injection; 20 mild cases and 1 fatal case after thirty days. 

At the Xew York Infant Asylum 107 cases of diphtheria occurred 
between September and January, 1895 (30 cases a month). In October 
bacteriologic examination showed diphtheria bacilli in almost one-half of 
the throats. 

January 16th 224 children were given immunizing doses of antitoxin, 
and up to February 15th only 1 case of diphtheria occurred. A second case 



568 THE INFECTIOUS DISEASES. 

then developed, and between February 15th and 27th, 5 cases. On the 25th 
245 children received antitoxin, and no cases occurred for thirty-one days. 
To sum up : before isolation and immunization 107 cases occurred in one 
hundred and eight days; after the latter was practiced, 5 cases in one 
hundred and twelve days. 

The occurrence of diphtheria during an epidemic of measles at the 
New York Foundling Hospital added greatly to the mortality of the dis- 
ease. During an epidemic of measles at that institution every child was 
given 400 units of antitoxin. The result was most encouraging, as is shown 
by the immunity conferred by the injection. 

In 149 cases of measles, 500 units of diphtheria antitoxin were given at 
the first appearance of measles symptoms. No cases of diphtheria secondary 
to measles occurred in any of those cases for a period of one month at least. 
Since the appearance of the later report another epidemic of measles has 
occurred at this institution. The children were given 500 units of anti- 
toxin each, but it was apparent in a number of instances that immunity 
from diphtheria did not last for more than eighteen days to three weeks, 
at which time several cases of diphtheria occurred, complicating or follow- 
ing measles, and generally proved fatal. This relatively shorter period of 
immunity from diphtheria in measles cases has been noted in France and 
Germany, and for this reason Slawyk recommends that the immunizing 
dose be repeated every two weeks in measles epidemics. 

W. P. Coues gives an account of an epidemic of diphtheria at St. 
Mary's Infant Asylum, in Boston, 1898. Fifty children were given doses 
of antitoxin, from 50 to 500 units, the small dose in a one-day infant. 
Urticaria occurred in 14 as the only bad result. From February 15th to 
March 22d there were 18 cases of diphtheria. After the latter date, when 
antitoxin was begun, there occurred no cases for three weeks. 

Krauss gives an extensive analysis of results of immunizing doses in 122 
hospital cases, which were divided as follows: 44 were scarlet fever cases, 
2 of which later contracted diphtheria; 31 cases of children were sent to 
the diphtheria pavilion and found not to have true diphtheria; no cases 
contracted it; 47 measles cases, many of them complicated; 1 developed 
diphtheria. 

Thus, of 122 cases, all of whom were more or less exposed to the dis- 
ease, and all ill with diseases most likely to be complicated by diphtheria, 
only 3 became infected, on the twenty-sixth, twenty-seventh, and forty-first 
day after inoculation. The dose of antitoxin ranged from 200 to 400 
units, the latter being given to the children with suspected diphtheria. 

In addition to the results of immunization at the New York Infant 
Asylum, the following report of Biggs will show the result at other insti- 
tutions ; — 



DIPHTHERIA. 

Table Xo. 77. 



569 






Place of 
- ation. 



Nursery and 

Child's 

Hospital 



Children 

Iiuiuuu ze 1. 



New York 

Juvenile 

Asvluni 



New York 

Catholic 

Protectory 



Bellevue 
Hospital 



Total. 



B i i" Dinfa 

theria l>ev«Ao|>- Caseg Deve , CaS(?g Develop- 



114 



11 



1 mild on 
the 19th day 



342 



Numbef of Cases of 
I'iphthe ia that 
Occurred in the Insti- 
tutions I'p viotM to 
Immunization. 




5 cases in 3 days 



one 30th 2 cases in 10 days, 
one 31st One or more cases 
one 55th in more than 90 
families 






Modern Treatment of Diphtheria. 

The treatment of diphtheria requires careful consideration in each and 
every case. Certain conditions must be met; therefore it is wise to look 
ahead. The treatment is divided into : — 

1. Hygienic. 

2. Prophylactic and specific. 

3. Medicinal. 

4. Dietetic. 

Hygienic Treatment. — Put the child to bed in a large airy room. 
The room must be free from draught and so arranged that proper ventila- 
tion can easily be carried out. Fresh air in the treatment of this disease is 
of prime importance. Pseudo-membranous deposits in the nose, pharynx, 
larynx, or tonsils will frequently cause a mechanical impediment to the 
entrance of oxygen. Carbonic acid poisoning can easily take place, and 
the entrance of fresh air into the lungs is of the greatest importance. In 
simple diphtheria, or if we have an extension of the croupous deposits into 
the bronchi, perfect oxygenation of the lungs is demanded. Having given 
attention to proper ventilation we must seek to maintain an equal tempera- 
ture in the room. The temperature of the sick room should be between 65° 
and 72° F. The entrance of sunlight is of prime importance. When we 



570 THE INFECTIOUS DISEASES. 

consider the great antiseptic properties of sunshine and its beneficial effect 
upon the patient, then we must see the importance of admitting as much 
light and sunshine as possible. 

The Bath. — Next in importance to fresh air and sunlight is the bath. 
Every patient with diphtheria should be sponged twice daily with a tepid 
sponge bath. The body should be briskly rubbed for a few minutes after 
the bath to stimulate the cutaneous circulation. By opening the pores of 
the skin we naturally favor elimination, hence it is advisable to encourage 
diaphoresis by attending to the skin. 

Specific or Antitoxin Treatment. 

- Manner of Administering the Antitoxin. — The greatest amount of 
care should be exercised in administering antitoxin. The skin of the pa- 




Fig. 174. — Glass Aseptic Antitoxin Syringe. 

tient, the physician's hands and the needle used should be rendered aseptic. 
It is a good plan to disinfect the syringe with alcohol before filling the 
same with the antitoxin. Abscesses need not form at the base of puncture 
if care and attention are bestowed to strict cleanliness. 

Part of the Body Chosen. — Wherever a loose fold of skin can be 
pinched up, for example on the thigh, the loose tissues of the abdomen, the 
outer portion of the chest, or between the shoulder blades, the needle 
should be inserted into the cellular tissue and the antitoxin gradually in- 
jected. The puncture should then be sealed with a drop of collodion. Fill 
the syringe with antitoxin, and expel all air before injecting the patient. 
Sudden death after the injection of antitoxin has been reported when this 
precaution was neglected; and air was injected into a vein. 

A convenient method of injecting antitoxin is with the syringe adopted 
by Messrs. Mulford and "Wampole. The glass barrel containing the anti- 
toxin has an aseptic piston-rod and needle attached. This does away with 
an extra syringe as each dose of antitoxin is contained in one of these 
aseptic holders. 



DIPHTHERIA. 571 

The Administration of Antitoxin Per Or em. — Some writers have ad- 
vocated giving antitoxin by the mouth. The writer has administered anti- 
toxin in drachm doses until a sufficient quantity of antitoxin was given. 
One thousand units were given in this manner, in a very mild form of 
diphtheria. The disease spread in spite of this administration and there was 
no apparent benefit from its use. When, however, 3000 units were given 
subcutaneously, the disease not only improved, but the child recovered. 

Administration of Antitoxin Per Rectum. — Several years ago the 
writer was induced to use antitoxin in various ways. He therefore injected 
2000 units into the colon. The part was first thoroughly flushed with soap 
and water to remove faeces, and after it was completely drained, the 
required dose of antitoxin was injected through a long rubber catheter. 
Most of the antitoxin remained and was absorbed. 

Several cases of this kind were reported at a meeting of the New York 
County Medical Association, in 189 7, by the writer. As it w r as impossible 
to control the sphincter in some cases a large portion of the antitoxin was 
lost. It was impossible, therefore, to state just how much of this healing 
serum remained and was absorbed. In several cases in which this was used 
an apparent benefit was manifested; on the other hand in a very malig- 
nant case in which the sphincter ani was relaxed, the antitoxin was not 
retained and flowed from the colon and rectum and was lost. I therefore 
cannot advocate the injection of antitoxin excepting by the subcutaneous 
method. 

It is well at the onset of a case of diphtheria, be it confined to the 
tonsils, to a large or small area, to treat the disease as though it were 
much worse than it appears. Locally we see the macroscopic evidence 
by the presence of the pseudo-membrane. We cannot see nor can we know 
how much toxin has been thrown out by the Klebs-Loeffler bacillus, as the 
same enters the general circulation. What is recognized as a toxic con- 
dition is no more or less than a given amount of poison thrown into the 
system by these poisonous bacilli. Acting upon our knowledge of the bac- 
teriology and pathology of this disease we can lay down certain rules for 
the guidance of any one in the treatment of diphtheria. First and fore- 
most it is necessary to give a sufficient quantity of antitoxin to neutralize 
any and all poison that may be in the system. 

The specific action of antitoxin is well known and universally recog- 
nized. 

Dose Required. — Mild Cases: The dose depends on the severity of the 
infection. The usual amount required for a child from 1 to 5 years old 
with a mild form of diphtheria is 1500 to 3000 units. If there is no effect 
noticeable within twelve to twenty-four hours, then a second injection of 
the same quantity should be given. A child 5 to 10 years of age should 
be given at least 3000 to 5000 units at its first injection, to be followed in 



572 



THE INFECTIOUS DISEASES. 



twelve to twenty-four hours by another injection of the same amount if 

there is no amelioration of the symptoms. 

Severe Cases. — When we are dealing with a severe toxaemia with marked 

general depression and large masses of pseudo-membranes in the throat, 

then at least 10,000 units of antitoxin 1 should be injected in the beginning. 

When the cervical lymph glands are enlarged and there is slight or severe 

evidence of stenosis, then at least 
10,000 units should be injected in 
the beginning. 

Indications for a Second and 
Third Injection of Antitoxin. — If 
twelve hours after the first injec- 
tion there is no visible effect on the 
pseudo-membranes, if the child is 
not brighter, if the appetite is poor, 
and if the hearts action is very 
poor, in other words, if there is no 
visible improvement, then by all 
means inject a second dose of anti- 
toxin. 

The necessity for the third in- 
jection depends upon the pulse, 
temperature, the condition of the 
glands of the neck, and upon the 
macroscopic condition of the 
throat. If no improvement exists, 
then the third injection is impera- 
tive. 

Laryngeal Stenosis. — It is al- 
ways a safe plan to give an injec- 
Fig. 175.-Tempera.ture Chart from a Case tion of 5000 ^^g. and if the 

of Diphtheria, showing the Specific Effect of , . •, -, . 

. * . « m * at 4. i stenosis does not disappear m 

Antitoxin on the Temperature. Note also rr 

the effect on the pulse. (Original.) twelve hours, I give an additional 

injection of 5000 units, so that in 
all 10,000 units may be injected during the first twenty-four hours; (read 
chapter on "Intubation"). 

The above treatment with antitoxin will be serviceable when we are 
dealing with a pure Klebs-Loeffier infection, but there are a great many 



190*- 


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1 It is frequently necessary to repeat the dose so that 10,000 units may be 
given during the first day of illness if no improvement is noted. The dose of 10,000 
units may be repeated during the first three days if no improvement is noted. I am 
in favor of large doses and watch the child's condition as the guide when sufficient 
antitoxin has been injected. 



DIPHTHERIA. 573 

cases in which we have a mixed infection, and the streptococcus infection 
predominates. 

There are contributing factors frequently leading to a fatal termination. 
Firet and foremosl is the presence of the streptococcus in addition to the 
Klehs-Loeffler infection. In these mixed infections we have in addition to 
the general diphtheria, a. distinct streptococcemia. In these cases antitoxin 
is inert as regards the streptococcus. We frequently have broncho-pneu- 
monia, nephritis, arthritis, otitis, and local abscesses due to the invasion of 
the streptococcus. To neutralize such mixed infections we require besides 
the Klebs-Loeffler antitoxin a stre23tococcus antitoxin or a potent antistrep- 
tococcus serum. 

Tlie bacteriological findings will therefore be the guide in the future in 
determining first, whether a culture from the throat shows a mixed or an 
unmixed infection and in addition to this bacteriological examination, the 
blood must be examined to determine the presence or absence of a strepto- 
coccemia. The treatment must be based on scientific data, hence, it should 
conform with the result of what is found by culture from the throat and by 
the thorough examination of the blood. 

If we can inject a sufficient quantity of antitoxin to stimulate cell 
activity and neutralize general toxaemia, 1 then we give our patient the great- 
est opportunity to eliminate this deadly poison and to begin convalescence. 

The ordinary shortcomings that are most freque?itly met with consist 
of placing too much reliance on the specific nature of antitoxin regardless 
of other vital necessities. In this infectious disease, ivhere there is marked 
leucocytosis and other evidences of subnormal hcemic conditions, the indi- 
cation next to antitoxin is for restorative treatment, especially nutrition. 

Dry Antitoxin. — Dry antitoxin is a golden-yellow crystalline substance 
quite soluble in sterilized water. 

Directions far Use. — The remedy must be dissolved immediately before 
use by adding from 1 to 4 cubic centimeters cold sterilized water by means 
of a sterilized pipette into a bottle of antitoxin. The solid serum dissolves 
slowly; the greatest caution must be used not to contaminate the solid 
serum, as it contains no antiseptic. Small vials containing 1000 units con- 
stitute a healing dose. 

It is then injected into the connective tissue of the intrascapular re- 
gion, buttocks, thighs, or in the loose, connective tissue of the abdomen or 
chest. A series of clinical results in severe and mild diphtheria was re- 
ported by me at the Section on Pediatrics of the American Medical Asso- 
ciation, 1899. Very good results were noted. 

The following case of diphtheria, complicated by laryngeal stenosis, 
will illustrate the mode of administration and its result : — 



l In septic diphtheria "where profound toxaemia exists an intravenous injection 
of 10,000 to 20,000 units of antitoxin should be used. 



574 



THE INFECTIOUS DISEASES. 



Lizzie G., born U. S. 

Family History. — Negative; sister had diphtheria last year. 
Habits and Surroundings. — Attends public school; tenement, two rooms; two 
adults, four children. Cleanliness leaves a great deal to be desired. Ventilation 
bad. 

Previous History. — No contagious diseases. Inclined to tonsillar inflamma- 
tions. Adenoids. 

Present History.— The source of infection is probably to be sought in school 
or Sunday school. Lymphatic diathesis. The disease began on April 21st, when the 
child seemed feverish, restless, and complained of sore throat. A physician, who 
was consulted, declared that the child was suffering from "catarrh." The mother 
says she noticed some white spots in the child's throat. There was anorexia, cough 
and difficulty in swallowing. During the following night the cough assumed a 
croupy, brassy character, and in the morning the mother 
found that the child was breathing rapidly and noisily, and 
that the fever, sore throat, headache and nausea were inten- 
sified. There was considerable prostration. In the after- 
noon I saw the case, with Dr. Geo. A. Saxe. The child pre- 
sented a considerable degree of laryngeal stenosis, so that 
we informed the mother that intubation would be nec- 
essary. 

Examination. — An anaemic child, fairly well nourished, 
but with feeble musculature. The skin pale, hot and dry. 
There was no eruption. Herpes labialis. The bowels were 
regular; no vomiting. The temperature was 101° F., the 
pulse 108; the respiration 48, shallow and noisy. The 
intercostal spaces and the suprasternal notch and sterno- 
costal angle are depressed at each inspiration. There is a 
croupy cough. The tongue is coated and moist. There is 
a slight nasal discharge. The conjunctivae are normal. 
There are enlarged glands on both sides of the neck, which 
are hard, mobile, and not painful to the touch. The tonsils, 
arch of the palate, and posterior wall of the pharynx show 
the presence of yellowish-gray spots of false membrane. 
They are exceedingly difficult to dislodge. The surround- 
ing mucosa is diffusely inflamed. A culture on serum agar 
was planted with some of the exudation, and within twenty- 
four hours sufficient growth appeared on the surface. The 
bacteriologist reported the presence of true Klebs-Loeffler 
bacilli. (Report New York Health Board, No. 2813.) 

There was no pain in the chest, there was distinct 
bronchial fremitus on palpation. Auscultation was ex- 
tremely difficult, on account of the laryngeal stenosis, and 
revealed sibilant and sonorous breathing, subcrepitant rales 
and pulmonary vocal resonance. Percussion sounds normal. 
Fig. 176. — Tempera- The heart action regular, no murmur. The abdomen nega- 
ture Chart from a tive. The faeces are of normal color and consistency. The 
Case of Diphtheria, urine specific gravity 1022, no albumin, no casts, quantity 
Showing Effect of Dry average, reaction acid, color normal. 
Antitoxin. (Original.) Diagnosis. Tonsillar and laryngeal diphtheria. 





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DIPHTHERIA. 575 

ProgH08i8. — Grave, on account of the amount of laryngeal steno-i- 

Treatment. — On the Baxne day, an hour after the first visit. Dr. Baxe injected 
1500 units of the dry antitoxin of Behring into the right hypochondriac region. 
Temperature at injection 102.4° F.j pulse 120; respiration 48. Calomel tablets, 
0.015 t. i. d. Inunctions of 25 per cent, mercurial ointment to' the neck. Semi-solid 
foods were ordered. At S.30 p.m. on the same day I found the child Buffering with 
severe laryngeal stenosis and immediately intubated. The relief was instantaneous. 

April 23d. On the following morning the child's respiration was perfectly 
normal, being at the rate of 24 per minute. The temperature was 101.2° F., the 
pulse 90, and the general condition considerably improved. There was still con- 
siderable cough and stringy mucus was expectorated. The child was given a mix- 
ture containing 2 grains of ammonium carbonate, one drop of the tincture of 
strophanthus, 20 minims of syrup of wild cherry in a teaspoonful of water. The 
bowels were regular. The other medication was continued in the same way. No 
more antitoxin was given. 

April 24th. The child's breathing is normal, and there is no sound of an oh 
struction, as there often is in intubated cases. The membranes disappeared from 
pharynx, tonsils, and palate. The examination of the heart and chest is negative. 
The herpes labialis and the swollen cervical glands are beginning to disappear. The 
temperature is 100.0° F., the pulse 84, and the respiration 24. The child sleeps well 
at night and has more appetite. 

April 25th. The general condition is very good. The bacilli have disappeared 
from the throat, as attested by bacteriological examination. The temperature is 
100.2° F., the respiration and pulse the same as on the preceding day. 

April 26th. The child's cough is less frequent and the breathing is normal. 
The appetite is very good, the tongue clean, and the cervical glands almost normal. 
The same medication is continued. The temperature is 99° F., the pulse 84, and the 
respiration 24. 

April 27th. The child was extubated (on the fifth day). The tube was coated 
with lime salts, but its lumen was free. There was no dyspnoea, and the child con- 
tinued to breathe easily after the extubation. The temperature was 98.6° F.; the 
general condition very good. 

In this case no sequelae were observed, though on the day after the intubation 
the child developed symptoms resembling those of a broncho-pneumonia. 

Dietetic Treatment. — As a tissue and blood builder no medication 
equals food. It is, therefore, imperative to support the general nutrition by 
proper feeding. Milk diluted with some cereal decoction, like oatmeal, bar- 
ley or rice, will be better borne than pure milk alone. Buttermilk or zoolak 
may be given. Sometimes it is necessary to partially peptonize milk to 
render it more absorbable. If the child is old enough the yolk of a raw egg 
can be added to the milk (egg-nog). Concentrated beef broth, chicken 
broth, clam broth or oyster broth should be thought of. When feeding, once 
in three hours, it is a good plan to give some of this concentrated broth, fol- 
lowed in three hours by a milk feeding, and so alternate. In this manner 
we give our patient milk once in six hours. Acid fruits, such as oranges, 
lemons, grapes, and cranberries are very well borne. When acid fruits are 
ordered they should be given an hour before milk feeding. Older children 
can be given raw scraped steak, calfs-foot jelly, and ice cream which is 



576 THE INFECTIOUS DISEASES. 

nutritious and pleasant. When it is difficult to feed by mouth owing to 
excessive vomiting or to anorexia, or where intubation has been performed, 
it is a good plan to let the stomach have absolute rest and to depend on : — 
Rectal Feeding. — [No more than two ounces should be injected at one 
time. 

Milk, predigested 1 ounce 

Starch water 1 ounce 

Laudanum 1 minim 

To be injected slowly through a colon tube, after both colon and rectum have 
been cleansed by a soap-suds enema. 

If the small nutritive enema is well retained we can repeat the injection 
once every four hours, and add the yolk of a raw egg to the above formula 
of milk, starch and opium. Xext in importance to giving the proper dose 
of antitoxin is the nutrition of the body which has just been considered. 

Elimination of Toxins. — The elimination of toxic elements can only 
take place by means of the bowels, kidneys, and skin. Xormally in febrile 
conditions there is a general torpidity of the emunctories. Thus it is ap- 
parent that a dose of calomel, citrate of magnesia, or an alkaline solution 
like the milk of magnesia or a laxative mineral water, will aid in the per- 
formance of these functions. 

Medicinal Treatment. — It is advisable to remove the putrid membranes 
from the nose and throat and also the catarrhal discharges. To do this, 
mechanical treatment consisting of the cleansing of the nose with a salt 
solution of the strength of one dram of table salt to one pint of water is 
useful. A weak (% per cent.) solution of permanganate of potash can also 
be used to cleanse the nose with the aid of a syringe (see Fig. 210). 

Septic products in the nose and throat will frequently lead to a fatal 
termination. Their presence is a constant menace to the blood by inviting 
toxaemia. In addition thereto they give rise to fever and not infrequently 
septic material will find its way from the nose and pharynx into the 
Eustachian tubes, causing abscesses. If neglected it may lead to mastoid 
involvement and brain abscesses or to septic meningitis, with little or no 
chance of recovery. 

By observing the enlarged lymph glands, it is surprising to see what 
good result is apparent after cleansing the nose and pharynx. 

Local Treatment of the Pseudo-membranes. — The solvent effect of local 
remedies I have never been able to see. "When papayotin has been used, I 
have been disappointed in its effect. Creosote vapors, by adding a dram of 
beechwood creosote to a pint of water and allowing the air to become im- 
pregnated with the vapor has shown some good in a few instances. Lugol's 
solution of iodine (half strength) applied by means of absorbent cotton, can 
be recommended. A steam atomizer containing a weak solution of (2 per 
cent.) sulphurous acid is sometimes of value. The latter has been used by 



DIPHTHERIA, 577 

me and certainly can be recommended when there are extensive necrotic 
patches. It is far better than peroxide of hydrogen. Other local 
treatment which I have used with benefit is the inunction of nnguentum 
Crede into the cervical glands, rubbed in at least fifteen to twenty minutes 
two or three times a day. An ice-bag worn continually can also be recom- 
mended when there is an extensive oedema. 

Oxygen is indicated and required when there is the slightest evidence of 
cyanosis. It will also relieve dyspnoea when present. It is especially indi- 
cated during broncho-pneumonia, which so often complicates diphtheria. 

Fever Treatment. — It is a wise plan to exclude antipyretic drugs during 
the treatment of fever in diphtheria. The best antipyretic measures con- 
sist in sponging with evaporating lotions such as alcohol and water or acetic 
ether, locally. Cold packs and flushing the bowel with cold water are very 
serviceable in some cases. When high fever, due to pneumonia, to nephritis 
or to any other complication exists, the same should be treated as though the 
disease existed independent of the diphtheria. 

When fever exists and the child cries continuously then the ears 
should be examined. Frequently an otitis media will keep up high fever 
until the drum is ruptured. Ten to 20-drop doses of sweet spirits of niter 
are valuable if given several times a day. During the febrile stage of 
diphtheria calomel in 1 / 10 to 1 / 2 -grain doses, repeated several times a day, 
is a useful adjuvant in fever treatment. 

Stimulation. — Owing to the depressing effect of the diphtheritic poisons, 
stimulation should begin early. Strychnine, 1 / 100 grain, for a child 1 year 
old, repeated three or four times a day, may be given. The dose can be 
gradually and cautiously increased until a systemic effect is noticeable. 
Children will tolerate very large doses of strychnine just as they will tolerate 
very large doses of whiskey. They can be combined. Tokay wine, cham- 
pagne and coffee are valuable cardiac stimulants. Caffeine citrate and 
sparteine are also serviceable for enfeebled heart's action. The prognosis 
of a case of diphtheria is certainly better in a case where the heart has been 
supported until the toxsemia has passed away. 

Paralysis. — The internal treatment of paralysis consists of strychnine 
and the usual restorative treatment. Galvanic and faradic electricity are 
good. Absolute rest in bed and gentle massage are indicated. 

Statistics of the Kaiser and Kaiserin Friedrich Hospital in Berlin 
show a very interesting comparison between the mortality before and after 
antitoxin was used. 

The death rate was 36.56, 35.57, and 45.78 in three successive years, 
or an average of 39.63 per cent. In the year 1894, when the serum treat- 
ment was first used, although experimentally, there were two interesting 
data: first, the mortality among cases treated with antitoxin was 16.6 per 
cent.; second, those treated without antitoxin, mortality 27.8 per cent. 



578 



THE INFECTIOUS DISEASES. 



In the following year (1895) all cases of diphtheria were injected with 
antitoxin; the mortality fell to 11.2 per cent. 

Immunity. — Four hundred and sixty children were injected with the 
object of producing immunity. Of these only 18 came down with diph- 
theria. All of these cases were mild and not one died. 



Table No. 78.— Diphtheria Cases — Willard Parker Hospital. 

TREATED WITHOUT ANTITOXIN. 



Year. 


No. Treated. 


Died. 


Mortality— Per Cent. 


-Recoveries— Per Cent. 


1889 


391 


79 


20.20 


79.80 


1890 


311 


67 


21.54 


78.46 


1891 


303 


85 


28.05 


71.95 


1892 


311 


79 


25.40 


74.60 


1893 


357 


108 


30.25 


69.75 


1894 


732 


205 


28.01 


71.99 


Total. 


2405 


623 


25.57 


74.42 



TREATED WITH ANTITOXIN. 



Year. 


No. Treated. 


Died. 


Mortality— Per Cent. 


Recoveries— Per Cent. 


1895 


825 


190 


23.03 


76.97 


1896 


860 


205 


23.84 


76.16 


1897 


881 


214 


24.29 


75.71 


1898 


612 


109 


17.81 


82.19 


1899 


781 


192 


24.58 


75.42 


1900 


823 


238 


28.92 


71.08 


1901 


919 


275 


29.92 


70.08 


1902 


1112 


271 


24.37 


75.63 


1903 


1281 


356 


27.79 


72.21 


1904 


1402 


356 


25.39 


74.61 


*1905 


478 


98 


20.50 


79.50 


Total. 


10574 


2504 


23.67 


76.33 



*On account of rebuilding the Hospital, no patients were received after June 17th. 



INTl'BATION. 



A comparative Btndj of the deaths before antitoxin was used and the 
presenl method o( treatment, where all cases receive antitoxin, can hardly 
be made. 1 frequently see septic cases sent to the hospital in a moribund 

condition. The city hospital is used as a dumping ground for all malignant 
cases, hence, the high mortality rate. The cases admitted belong to the 
Laboring class of people. As these people are very poor, they delay sending 
for a physician until severe laryngeal stenosis sets in. When the disease 
has gained headway and there is a general septic condition, recovery, as a 
rule, is doubtful. 

Intubation. 

When laryngeal stenosis occurs during a case of diphtheria, then we 
must prepare for intubation. 

The following symptoms demand intubation: — 

Labored breathing. 

A gradual and progressive dyspnoea. 

A failing or intermittent pulse. 

Cyanosis showing defective oxygenation. 

Eetraction of chest wall most marked at epigastrium or at the clavicles. 

When the accessory muscles of respiration are brought into play. 

When the child is compelled to sit upright in order to breathe and 
pulls at its neck and throws itself from side to side, gasping for breath. 

Indications for Intubation. 1 — "The indications for intubation are 
marked by a more or less sinking in of the yielding portions of the chest, 
lower ribs and sternum, episternal notch, and supra-clavicular regions with 
inspiration. It means simply that air cannot gain entrance to the lungs in 

Table No. 79. —Diphtheria Cases — Willard Parker Hospital. 






Year. 


No. Treated. 


Died. 


Mortality 
Per cent. 


Recov ries 
Per cent. 


Intubations. 


Recover- 
ies 
Inclusive. 


Recoveries 
Per cent. 


1901 


919 


275 


29.92 


70.03 


222 


70 


31.53 


1902 


1112 


271 


24.37 


75.63 


258 


116 


44.92 


1903 


1281 


356 


27.79 


72.21 


352 


123 


34.94 


1904 


1402 


356 


25.39 


74-61 


410 


193 


47. 


*1905 


478 


98 


20.50 


79.50 


154 


86 


56. 


Total 


5192 


1356 


26.12 


73.88 


1396 


588 


42.13 



*On account of rebuilding the Hospital, no patients were received after June 17th. 



From O'Dwyer's treatise on "Intubation" in his book, "Diphtheria and Croup," 



1889. 



580 THE INFECTIOUS DISEASES. 

Table No. 80. — Statistics of Intubation Cases, at the Willard Parker Hospital. 



1901 


1902. 


Month. 


Discharged. 


Died. 


Fer cent. 
Recover. es. 


Month. 


Discharged. 


Died. 


Per cent 
Recoveries 


Jan. 
Feb. 
March. 
April 
May- 
June 
July 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 


2 

2 
8 
6 
7 
4 
2 
5 
4 
8 
9 
7 


15 
11 
17 
15 
33 
10 
10 
12 
13 
9 
13 
20 


11.76 

15 38 
32.00 
28.57 
35.00 
28.57 
16.67 
29.41 
23.52 
47 05 
40.90 
25.92 


Jan. 

Feb. 

Ma'ch 

April 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 


11 

10 

12 

18 

4 

17 

1 

5 

8 

6 

9 

13 


10 

10 

20 

28 

14 

10 

9 

8 

7 

3 

11 

14 


52.38 
50.00 
37.50 
39.13 
22.22 
62.96 
10.00 
38.46 
53.33 
66.67 
45.60 
48.15 


Total 


66 


158 


334.75 


Total. • • 


114 


144 


525.80 


General Average of Recoveries for 1901, 

27.89. 


General Average of Recoveries for 1902, 
43.81. 



Improvement in 1902 over 1901, 15.92 per cent. 



sufficient quantity to fill the partial vacuum created by the expansion of the 
chest, and the wall recedes under the weight of the atmosphere. It is very 
marked in very young or rachitic children owing to the greater elasticity of 
the ribs. But it should be remembered that this condition is not peculiar 
to stenosis of the larynx and trachea, as it is produced to a lesser degree by 
obstruction in any part of the respiratory tract that interferes with the 
free inflation of the lungs. It is found in capillary bronchitis, extensive 
deposits of pseudo-membrane in the bronchi, atelectasis, and to some extent 
even in broncho-pneumonia. Kecessions at the root of the neck are more 
significant than those below, as the violent contractions of the diaphragm 
aid in drawing in the free border of the ribs and sternum. 

"When recessions are marked there is little or no respiratory murmur 
over the posterior portion of the chest, but this symptom is not always avail- 
able owing to the laryngeal stridor. 

"Atelectasis with excessive quantity of blood in the lungs, as would 
naturally be expected, is the result of death from obstruction in the 
larynx, but there are exceptions to this rule, and these organs are occa- 
sionally found distended with air and containing less than the normal 
amount of blood. This acute general emphysema, which produces bulging 
of the parts that usually recede, is caused by greater impediment to expira- 
tion than inspiration, and air accumulates in the lungs in the same manner 



I NITRATION. 



681 



Table No 81. — Tlie Following Tabic Shows the Results from Intubation in Cases of 
Laryngeal D phtheria Tread d at flic Municipal Hospital, Philadelphia, 
from 1S94, to 1908. Incusire. 



1 Of those who received antitoxin th j death rate was 52.94 per cent. 
9 24 per cent, of this number did not receive antitoxin. 



Year. 




1 1 » 1 1 1 1 » : 1 1 1 • . 1 

Casts. 


^ .. Mortalitv 
I "' i,,, ' s - Per Cent. 


1894 


Without antitoxin 


100 


75 


75.00 








1895 


About 50 per cent, received antitoxin . . . 


122 l 


67 


54.91 


1896 


"With antitoxin . . 


156 2 


94 60.25 








1897 


U (< 


182 


127 


69.78 








1898 


(1 C< 


149 


104 


69.99 








1899 


a ci 


165 


97 


58.78 








1900 


(i IC 


202 


111 


54.95 








1901 


u ii 


139 


66 


47.47 








1902 


(1 u 


110 


54 


49.09 








1903 


a u 


110 


55 


50 00 








To'al 




1435 


850 


59.23 









as in spasmodic asthma. It is not common in croup, but is worth remem- 
bering. It is also occasionally found in capillary bronchitis. 

"The downward movement of the larynx with inspiration is pathogenic 
of serious obstruction in this organ, and is also the result of atmospheric 
pressure, the air being prevented from entering with sufficient rapidity to fill 
the partial vaccuum below. It is readily detected in adults, but not so 
in children, owing to deeper situation of the larynx in the latter. 

"This symptom is not present in stenosis of the trachea, owing to the 
great elasticity of this tube, which permits of considerable motion on itself 
without displacing the larynx. 

"Abiding cyanosis is too late a symptom to wait for, and besides, it is 
uncertain, as fatal obstruction may exist in the glottis with extreme pallor 
on the surface. This pallor of asphyxia is produced by the excessive 
quantity of blood drawn into and stored in the lungs by the cupping-glass 
action of inspiration when the air is almost excluded. The blood in the 



582 



THE INFECTIOUS DISEASES. 



cutaneous capillaries is thus reduced to a minimum, and this, although 
highly charged with carbonic acid, only serves to increase the paleness, on 
the principle that the addition of a little blue makes a clearer white. 



Table No. 82. — The Following Table Shows the Cases and Mortality of Diphtheria 

(Including Membranous Croup) in the Municipal Hospital, 1 Philadelphia, 

from 1890 to 1903, Inclusive. 





PRE-ANTTTOXIN PEEIOD. 




Year. 


Cases. 


Deaths. 


Mortality— Per Cent. 


1890 


12 


3 


25.00 


1891 


29 


1 


3.44 


1892 


183 


48 


26.22 


1893 


217 


62 


28.57 


1894 


465 


154 


33.12 


Total 


906 


268 


29.58 



ANTITOXIN PEEIOD. 



Year. 


Cases. 


Deaths. 


Mortality— Per Cent. 


1895 


706 


190 


26.91 


1896 


869 


193 


22.2 


1897 


1295 


300 


23.16 


1898 


1229 


297 


24.16 


1899 


1373 


275 


20.02 


1900 


1299 


264 


20.31 


1901 


889 


174 


19.57 


1902 


601 


137 


22.79 


1903 


746 


170 


22.78 


Total 


9007 


2000 


22.2 



1 1 am indebted to Dr. Welch for above statistics. 



INTUBATION. 



583 



T.vi'.: Diphtheria the Bodon OU$ HoqritaL 1 

CASKS rBKATKD WITHOUT ANTITOXIN. 





kted. 




Mortality 

IVr 


«ent. 


Intubations, 


Per 


odai 


1889 


589 




16.17 


54.88 


128 


18.75 


Years 


1890 




151 




63.61 


50 


15.05 




r 1891-2" 


237 


105 


H 30 


5.69 


16.00 




1892-3 


37 


I-.", 


47.80 


52.19 


65 


13.84 


Financial 
Years < 


1 893-4 


419 


203 


4-. 44 


51.55 


109 


17.43 


1-94-5 ' - 26 6 


38.10 61.fi 


89 


16.85 




Feb. 1 

to Sept. 1 

1895 


611 3 111 


18.16 


81.83 


39 


28.20 




Total 


3296 1260 


38.22 61.77 




17.45 



CASES TEEATED WITH ANTITOXIN, 



Year. 



N . 
Treat ed. 



Died. 



Mortality Recoveries 
Per cent". ; Per cent. 



Financial 
Years 



Sept. 1 to 
Jan. 31 
1895-6' 



1896-7 



Calendar 
Years 



1897-fl 



1898 



B44 



96 



11.3" 



B8.62 



1889 



13-7 



276 



14.61 



85.38 



Intubation?. 



224 



1-1 



13.04 



-17 



97 



11.8: 



86.95 



— .12 



146 



171 



Recoveries 
Per cent. 



54.43 



35.26 



54.11 



40.84 



1899 


1621 


162 


9.99 


90.00 


192 


67.18 


1900 


2547 


293 


11.50 




259 


66.40 


1901 


1576 


185 


11.73 




184 


68.47 


1902 


1008 


111 


in. 20 


89.79 


145 


66.20 


1903 


1179 


138 


11.70 


•~«. Of) 

*5.2S 


139 


73.38 



Total 12-68 



1539 



11.95 



88.04 



1439 



59.54 



1 1 am indebted to Dr. McColluin f'jr above statistics. 

'Thirteen months included in year l>91-2. 

'Some of these patients received antitoxin, but how many it is impossible to say. This explains the 
comparatively low death-rate from Feb. I, 1893 to Sept. 

4 From Sept. 1, 1*95. at which time the South Department was opened, to Dec, 31, 1903, every patient 
ill with diphtheria received antitoxin. 



584 



THE INFECTIOUS DISEASES. 



"The temporary cyanosis which comes and goes with the paroxysmal 

dyspnoea of the second stage of croup is of no particular significance. 
Children seldom remain long in one position when suffering severely from 
want of breath, and continued restlessness, if consciousness be unimpaired, 
is therefore an important indication that it is time to afford relief. 




^^^ggroggi 



^ 



Fig. 177. — Introducer with Tube Attached. 




Fig. 178. — Introducer with Tube and Detached Obturator. 




Fig, 179. — Introducer Holding Foreign Body Tube. 

"As far as the necessity for intubation is concerned, it matters little 
as to the real nature of the obstruction, provided it be in the larynx and not 
a foreign body. It may be croup, simple lar}mgitis, oedema of the glottis, 
paralysis, spasm, or even a neoplasm, In the latter it will tide over the 



INTUBATION. 



r>sr> 




Fig. 180.— Extubator. 




Fig. 181.— Built-up Tubes for Granulation Tissue. Useful for 
treatment of "Retained Tubes." 




Fig. 182.-Fiseher>s Corrugated Rubber Tube to be Used for Intra-laryngea. 
Medication in Chronic Stenosis (Recurring Stenos.s). 



586 THE INFECTIOUS DISEASES. 

immediate danger of asphyxia, and leave more breathing room to facilitate 
the radical operation." 

Dorsal Method of Intubation. — This method is the most convenient as 
it does away with the necessity of several assistants. I have frequently in- 
tubated in the dorsal position without any assistant. This method appeals 
to me as very valuable in emergencies, especially so when a physician is 
called out of town where no trained assistant is available. The method of 
introducing the tube is the same as that described as the O'Dwyer method. 
The dorsal method has been advocated by the attending and resident staff 
at the Willard Parker Hospital and is the method employed there by Dr. 
Burckhalter, Dr. Lynah, and Dr. Throne. 

The gag should be inserted in the left side of the mouth, and slowly 
opened. The trained nurse steadies the child's head and holds the gag in 
place. With the child flat on its back, the hands firmly held by a blanket 
encircling the body, the physician stands on the right side of the child and 




Fig. 183. 1 — The Mummy Bandage, showing child in proper position for 
the dorsal method of Intubation. All instruments required are carefully 
arranged. ( Original. ) 

introduces the index finger of his left hand in the median line until' the 
epiglottis is felt. The epiglottis should be raised and fixed. The tube 
should then be guided with the right hand of the operator, along the left 
index finger and inserted into the cul-de-sac of the larynx. It would be 
profitable to read O'Dwyer's description of the method of intubation which 
I append here, the only difference being that O'Dwyer recommends the sit- 
ting position, whereas I advocate the dorsal position. 

Upright Method of Operating.— "The nurse or person who holds the 



J The set of photographs illustrating Intubation, Extubation, and Gavage were taken 
in the wards of the Willard Parker Hospital. I am indebted to Miss Henry, the super- 
vising nurse, Miss Dunwoodie, the head nurse, and Dr. T. De L. Burckhalter and Dr. 
Lynah,the resident and assistant resident physicians, for their uniform courtesy and kind 
assistance with my illustrations and clinical details. 




Fig. 184. — Intubation. First step in operation: The handle of introducer 
parallel to the body axis; the top of the tube just entering the larynx. (Original.) 




Fig. 185. — Intubation. Second step in operation: Handle of introducer elevated; 
the tube sinking into larynx as the handle of introducer is elevated. (Original). 

(587} 



588 THE INFECTIOUS DISEASES. 

child should be seated on a solid chair with a low back, and the patient 
placed on the lap with head resting on left shoulder of nurse in order to 
leave the gag free. The hands can either be held or, still better, secured by 
the sides, by a towel or sheet passed around the body and left in that 
position until the tube is inserted and the string removed. Fastening the 
hands in front of the chest or thick garments in the same location renders 
it more difficult to depress the handle of the introducer sufficiently to carry 
the tube over the dorsum of the tongue. 

"The gag is then inserted well back behind or between the teeth in the 
left angle of the mouth and opened widely, care being taken not to do it 
too suddenly or to use too much force. In children who have not at least 
one bicuspid on the left side, the gag should not be used, as it slips forward 
on the gums, and, besides being in the way, is liable to injure the incisor 
teeth. There is little difficulty in these cases, in keeping the mouth suffi- 
ciently open with the finger, if carried far enough to the patient's right 
to be out of range of the front teeth. Allowing the child to compress the 
finger between the gums for a few seconds until the jaws relax, before carry- 
ing it into the fauces, avoids the necessity for using force. 

"An assistant stands behind the patient and holds the head firmly by 
placing one hand on either side, and at the same time slightly elevates the 
chin. The operator stands in front of the patient, holding the introducer 
lightly between the thumb and fingers of the right hand, the thumb resting 
on the upper surface of the handle, just behind the knob that serves to 
detach the tube, and the index finger in front of the trigger support under- 
neath. Held in this manner it is impossible to use force enough to make 
a false passage, while if firmly grasped in the hand the beginner may, uncon- 
sciously, exert sufficient force to lacerate the tissues. 

"The index finger of the left hand is carried well down in the pharynx 
or beginning of oesophagus and then brought forward in the median line, 
raising and fixing the epiglottis, while the tube is guided along beside it into 
the larynx. If any difficulty is experienced in locating the epiglottis, it is 
better to search for the cavity of the larynx, a cul-de-sac into which the tip 
of the finger readily enters, and which cannot be mistaken for anything else. 
Once in this cavity the epiglottis must be in front of the finger and the latter 
is then raised and pressed toward the patient's right to leave room for the 
tube to pass beside it. The distal extremity of the tube should be kept in 
contact with the finger, and even directing it a little obliquely toward the 
right side of the larynx if necessary to get inside the left aryepiglottic fold, 
especially in very young children. The handle of the introducer is held 
close to the patient's chest in the beginning of the operation, and rapidly 
raised as soon as the end of the tube has passed behind the epiglottis, other- 
wise it will slip over the larynx into the oesophagus. 

"Some operators hold the introducing instrument in the horizontal 




Fig. 186. — Extubation. First step in operation: The gag in position. The extractor is 
guided along the left index ringer until the beak enters the lumen of the tube. (Original. ) 




Fig. 187. — Extubation. Second step in the operation : The beak of the extractor 
holding the tube firmly : the operator withdraws the tube. (Original.) 

(589) 



590 THE INFECTIOUS DISEASES. 

position until the tube is well back in the fauces, and then swing it around 
to the middle line and complete the operation in the usual manner. The 
beginner is liable to forget the latter movement, which is the only objection 
to this plan. 

"As soon as the cannula is inserted the introducer with obturator at- 
tached is withdrawn by pressing forward the button on the upper surface 
of the handle with the thumb, while counter-pressure is made with the 
index finger on the trigger beneath. In removing the obturator — the joint in 
the shank of which is intended to facilitate this part of the operation — 
the movements required for insertion are reversed. To prevent the tube 
from being also withdrawn, the finger must be kept in contact with its 
shoulder either on the side or posteriorly. 

"The tube should be carried well down in the larynx before detaching 
it, otherwise the lower aperture will be left open and liable to strip off 
pseudo-membrane as it is subsequently pushed home with the finger. 

"The gag is removed as soon as the tube is in place, but the string is' 
allowed to remain in place long enough to be certain that the dyspnoea is 
relieved and that no loose membrane exists in the lower portion of the 
trachea. In some cases the presence of the thread is desirable because it 
excites more coughing, which is necessary to expel accumulated secretions 
and to inflate any collapse of the lungs that may have taken place. In 
removing the string the finger must be reinserted to hold the tube down, 
but the gag is rarely necessary, as children old enough to understand readily 
open the mouth for this purpose." 

The characteristic tubal cough due to a rush of air through the tube 
when in the larynx, if once heard will always be remembered. Usually the 
presence of the tube excites a paroxysm of coughing and large quantities of 
mucus and membrane will frequently be expelled. The effect most no- 
ticeable is the immediate relief of the laryngeal stenosis. It is wise to wait 
five or ten minutes before withdrawing the silk thread that has been placed 
in the tube. After cutting the thread the finger should again be placed 
over the head of the tube, and the tube firmly pressed down while the string 
is withdrawn. 

There are several important points which must be emphasized in this 
operation. In the first place no force is necessary. "Occasionally a mo- 
mentary spasm retards the immediate entry of the tube into the larynx, in 
which case rather than use force, it is best to wait a second or two for this 
to relax, when the tube will fall into place. The introducer should be held 
lightly between the end of the thumb and finger, and not grasped firmly in 
the hand. The introducer should be kept exactly in the middle line, other- 
wise the obturator will pinch in the caliber of the tube and drag the latter 
with it as it is withdrawn. It often happens that the child manages by one 
effort to slip down in the nurse's lap, while the grasp that the assistant 



I Nil BATION, 



691 



exerts tilts the head back, and the tube may impinge on the posterior wall of 
the larynx. The lines and angles must be maintained to insure quick 
intubation. The lark of observance and of carelessness in these points 
explain many failures of inexperienced operators. //' the tube is not properly 

placed at the first attempt, it is better to begin all over, making repeated 
short attempts, if necessary, rather than a single prolonged one." 

Accidents During Intubation. — An inexperienced operator will fre- 
quently be rewarded by fatal asphyxia. Prolonged attempts to introduce 
the tube will result in apneea. 




Fig. 188. — Baby K., nursing infant, eleven months old, suffered with 
Laryngeal Diphtheria complicated by Broncho-pneumonia. Stenosis requiring 
intubation. Case seen in consultation with Dr. Kahrs in Bronx. Tube re- 
mained in larynx nine days. Child recovered. Private practice case. (Orig- 
inal.) 



"Ten seconds is the longest time that should be occupied in each 
attempt, if the child is suffering from urgent dyspnoea at the time/' A 
child cannot breathe while the finger is in the throat. Repeated attempts 
will so exhaust the vitality of a child that this must be reckoned with. 

"The expert seldom requires more than five seconds to complete the 
operation, except in difficult cases, such as a very small mouth and throat, 



592 THE INFECTIOUS DISEASES. 

marked increase in the size of the tonsils, especially if chronic; extreme 
tumefaction of the epiglottis and aryepiglottic fold, which changes or ob- 
literates the usual landmarks, and the struggles and resistance sometimes 
offered by older children when intractable. In the latter, although I have 
never had to resort to it, the administration of an anaesthetic would be less 
injurious than the exhaustion and cyanosis induced by a prolonged struggle 
without it. 

"If the tube has once passed on the outside of the larynx, and this is 
recognized before it is detached from the obdurator, it is useless to try to 
rectify the position without first depressing the handle of the introducer as 
in the beginning of the operation, because, owing to the length of the tube, 
the palate arrests the upward movement before the distal extremity reaches 
the level of the glottic opening. 

"In croup the ventricles of the larynx are usually obliterated by swelling 
of the tissues and covered over by the pseudo-membrane, and therefore 
seldom offer any obstacle to the passage of the tube on the first introduc- 
tion; but when the stenosis persists longer than usual and reintroduction 
becomes necessary, it is well to remember that this may be a source of ob- 
struction. The tube once having entered a ventricle, a moderate amount 
of force is all that is necessary to make a false passage. I have known this 
accident to occur when the operator was unconscious of having used any force 
whatever. If the patient's head be thrown too far back, the tube may also 
be arrested by coming in contact with the anterior wall of the larynx or 
trachea." 

An accident, which fortunately is very rare, is the pushing of membrane 
downward. In this condition stenosis will not be relieved. In such cases 
it is advisable to extubate at once, and to reintubate by using one of the 
specially constructed tubes. 

Specially Constructed Tubes (see Fig. 181). — Caliber tubes, made of 
metal, also known as foreign body tubes, have a much wider lumen than 
the ordinary tubes used for intubation. They are also shorter. Through 
these tubes large membranes are frequently expelled. There are instances, 
however, where large pseudo-membranes extend into the trachea to the 
smallest ramifications of the bronchi. Violent coughing paroxysms fre- 
quently dislodge these membranes, so that distinct casts of the trachea 
and its bifurcation can be plainly made out. Several of these casts were 
seen by me during my service at the Willard Parker Hospital. 

Intubation in Chronic Stenosis of the Larynx. — O'Dwyer's rules and 
indications for the performance of intubation in chronic laryngeal stenosis, 
are as follows: (1) Cicatricial stenosis, due to injury to the soft parts from 
syphilis, irritants, and traumatism. (2) Narrowing of the space both below 
and above the vocal bands from the products of chronic inflammation — 
simple, tuberculous, specific, malignant, or otherwise, and including such 



INTUBATION. 593 

conditions as the so-called pachydermia Laryngis, and corditia vocalia inferior 
hypertrophica. (3) It is especially valuable in cases in which tracheotomy 

has been performed, and, when the tracheal cannula having been worn for a 
considerable Length of time, the upper part of the trachea is filled with 
granulations and the laryngeal muscles have become weakened from disease. 
In this condition intubation has effected many brilliant cures. (4) In 
papilloma of the larynx it has been found helpful in a fair proportion of 
cases, although its results in this disease are less satisfactory than in most 
others in which it has been employed. (5) Deformities of the larynx from 
injury or disease of its cartilaginous framework, which have resulted in 
constriction of the caliber of the organ, have been cured by it. (6) It has 
also been used, with excellent results, in anchylosis of the crico-arytenoid 
articulations, and in arthritis deformans of the same part. (7) It is useful 
in various affections of the nerves of the larynx; for instance, in hysterical 
contraction of the abductors, "aphonia spastica." 

Edwin Eosenthal 1 advises a spray of peroxide of hydrogen as a pre- 
liminary to intubation. Eosenthal does not believe that heart failure, 
which is in reality toxaemia, can be cured. He insists on cardiac stimulants 
and gives strychnine from the beginning, in increasing doses. 

In a paper published by W. L. Stowell, the following statistics 
occur : MacXaughton and Maddern reported 5506 intubation cases, with 30 
per cent, of recoveries. Dillon Brown reported 276 intubation cases, with 
calomel fumigations, and 49 per cent, of recoveries. The collective investi- 
gation of the American Pediatric Society now places the mortality of 
laryngeal diphtheria, or croup, at 21 per cent. ; and in intubated cases with 
antitoxin at 27.24 per cent. 

The Tolerance of the Larynx for the Intubation Tube. — I have fre- 
quently seen children walking around the wards of the Willard Parker 
Hospital who have worn intubation tubes about two years. When one con- 
siders the anatomical structure of the larynx, it is surprising that no 
inflammatory condition results from the presence of this foreign body. In 
the chapter on "Broncho-pneumonia" I report a case of diphtheria com- 
plicated by croup and later by broncho-pneumonia. Intubation w^as re- 
quired for the relief of laryngeal stenosis. The child coughed violently and 
expelled the tube so frequently that the case had in all twenty intubations. 
The case finally recovered. 

Ulcerations due to the intubation tube have been seen by me : — 

(1) In the cricoid division of the larynx, just below the vocal cords. 

(2) At the base of the epiglottis, from pressure during the act of 

swallowing. 

(3) On the anterior wall of the trachea near the distal end of the tube. 



1 Archives of Pediatrics, June, 1903. 

as 



594 



THE INFECTIOUS DISEASES. 



Ulcerations resulting from an intubation tube have been seen by me 
post-mortem in children that were fed by gavage. I have also seen ulcera- 
tion where children were fed by the natural methods. I believe that feed- 
ing with the swallowing movements incidental to the same produces ulcera- 
tion at the lower end of the tube, because of the up and down riding of the 
tube. 

A post-mortem specimen of larynx and trachea was recently (October, 1904) ex- 
amined by me at the Willard Parker Hospital. The child was in the hospital twenty- 




Fig. 189.— Gavage. 



Method used in Forced Feeding at the Willard Parker 
Hospital. (Original.) 



one days, it was therefore an acute laryngeal stenosis. Three ulcerations existed 
at the cricoid cartilage and nine other ulcerations existed at the distal end of the 
tube. 

Feeding After Intubation. — Various methods of feeding are in vogue, 
and each clinical observer seems to be satisfied with his particular method. 
Whenever possible we should try to resort to the usual mouth feeding. I 
invariably feed semi-solid food, such as bread soaked in milk, custard, junket, 
cornstarch, or rice pudding, soft boiled eggs, if the child's age warrants it; 
also concentrated soups and broths, calfsfoot or chicken- jelly, water ices 



INTUBATION, 



595 



and ice cream. These articles of food I have found besi adapted in a very 
extensive experience in hospital and consultation practice. 

In very young infants, breast or bottle-fed, great care Bhould be 
eised with the feeding. If a breast-fed child refuses to nurse, the breast- 
milk can be pumped off and the infant fed every three or four hours by 
spoon. 

My advice in intubated cases: Use natural methods of feeding — do 
not use gavage — choose simple ways. Eectal feeding may be tried if 
vomiting occurs. 




Fig. 190. — Casselberry Method of Feeding. (Original.) 

The Casselberry method of feeding consists in laying the child flat on 
its back across the nurse's lap, with the head below the level of the body. By 
this means we avoid introducing liquids into the larynx. 



Intubation - in Private Practice. 

The management of a case of intubation in private practice should be 
carefully considered. Xo child should be permitted to wear a tube in the 
larynx without the constant supervision of a trained nurse. In the Willard 
Parker Hospital we have competent trained nurses both night and day, and 
a physician is always ready to respond in case of emergency. I have fre- 



596 



THE INFECTIOUS DISEASES. 



quently intubated in private practice and always give the following orders 
to the trained nurse : — 

First. — If the breathing becomes labored or if the child has a sudden 
increase in the number of respirations, notify the physician at once. 

Second. — Watch the pulse; a sudden increase in the pulse-rate or a 
sudden intermittent pulse means danger. 

Third. — If cyanosis or sudden apnoea occurs, possibly caused by a 
plugging of the lower portion of the tube with membrane, notify the physi- 
cian so that the tube can be extubated and a tube of larger caliber inserted. 

Fourth. — If the tube is sud- 
denly expelled during a paroxysm 
of coughing (auto-extubation), a 
hurry call should be sent to the phy- 
sician. 

What to Do in an Emergency. 
First. — Give a mustard foot-bath 
or apply a mustard plaster over the 
heart to stimulate the circulation. 

Second. — Give 5 to 10 drops of 
aromatic spirits of ammonia with an 
equal quantity of whisky. Nitro- 
glycerine can be given in 1 / 100 -grain 
doses every hour, hypodermically if 
necessary. 

Third. — Eelieve the stenosis, if 
it exists, by careful intubation. 

Fourth. — If an expert intuba- 
tor is not at hand, or if intubation 
pushes membrane downward so that 
the stenosis persists, resort to trache- 
otomy. 

Eegarding extubation, my rule 
in private practice is to extubate on 
the fifth day, or on the morning of 
the sixth day, provided the tempera- 
ture is normal and no complication 
exists. It is safer to leave a tube in 
the larynx one day longer rather 
than rislc the necessity of reintuba- 
tion. 

Mamie B., 2 years old, was seen by 

Fig. 191. — Temperature Chart from me through the courtesy of the attending 

a Case of Diphtheria: Croup, In- physician, Dr. H.Weinstein, on the second 

tubation. (Original.) day of her illness. There were Datches 







INTUBATION. 597 

of diphtheria visible on the pharynx and tonsils. The temperature was L01 7 : ,° F., 
pulse 140. There was also Laryngeal Involvement ooticeable by the croupy cough. 

An injection of -2.000 units of antitoxin was first given. The colon was flushed and 
the bowels thoroughly emptied. A dose of calomel was given and milk and 
albumin wate. ordered, for the diet. 

Nasal irrigations of saline solution were ordered every two hours. An ice-bag 
was applied to the neck. On the third day the temperature rose to 102° F., pulse 
130, respiration 30. Breathing labored — considerable retraction of the chest — cough 
very croupy. Large quantities of mucus were expectorated. The pulse was 146, 
respiration 40. Stimulation was demanded and 1 drachm of whisky was given 
every hour. Laryngeal stenosis was so severe that a hurry call was sent to me to 
intubate. The child was quickly intubated. A No. 3 rubber tube having a coating 
of gelatine and alum was inserted. The stenosis was immediately relieved. The 
child appeared comfortable and fell asleep. Six hours after the intubation the tem- 
perature vvas 103° F., pulse 140, respiration 40. Cold sponging was ordered and 
owing to severe coughing when liquids were given, semi-solids were ordered while 
the intubation tube was in situ. On the following day the temperature dropped to 
101.0° F., and on the third day after intubation the child was practically normal. 
The tube was left in the larynx five days, and as soon as the temperature dropped 
to 99° F. the child was extubated. The patient made an uneventful recovery. No 
complications followed. I might add that the usual rule of administering 15 grains 
of bromide of sodium or Via grain of sulphate of morphine, as an anti-spasmodic one 
hour before extubation, was not given in this case. 

A Study of the Condition of the Upper Air Passages Before and 

After Intubation of the Larynx. Also, an Inquiry Into 

the Method of Feeding Employed in the Cases. 1 

Laryngeal stenosis will frequently be relieved after one intubation and 
one extubation. There are other cases which require several intubations 
before a permanent cure results. 

I have examined a series of children that were operated upon several 
years ago. Two classes of cases have been selected. One series was seen at 
the "Willard Parker Hospital, and the cases were intubated by the resident or 
assistant resident physician. The cases in this series cover the years 1896 to 
1900, and were under treatment of Dr. E. G. Bryant and Dr. Somerset. 

First Series. Children Intubated in the Hospital. — The children ad- 
mitted to the Willard Parker Hospital belong, as a rule, to the laboring 
class of people. Exceptionally, the service at the hospital receives patients 
of a better class. All of the children examined by me belonged to the tene- 
ment house district of New York City. The houses are densely crowded 
tenements having a minimum quantity of fresh air and sunlight. It is 
not unusual to see cases from such unsanitary surroundings ending fatally. 
These children are, as a rule, very anaemic and are extremely susceptible to 
infection. 



1 Paper read before the International Medical Congress held at Madrid, Spain, 
April 26, 1903. 



598 



THE INFECTIOUS DISEASES. 



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General condition fair. Sub- 
ject to dyspnoelo attacks. 
Following year had mea- 
sles and croup. Influenza 

and bronchitis lately. 

Lymph nodes enlarged. 
Otitis, left ear. Rachitis. 
Measles and bronchitis 
after discharge. 


General condition fairly 
good. Measles shortly after 
convalescence. Mild attack 
of croup two years later. 
Dyspnoea at times, due to 
catarrh. 


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moved after leaving hospiiai 

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monia. 


Since leaving hospital, pneu- 
monia, laryngitis and stra- 
bismus. Returned after 
live years with mild diph- 
theria. (No intubation). 


Condition of Chest. 


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INTUBATION. 

Eospital I asi 8: lu. 
- - [Hired one intubation 
required three intubations 
[uired four intubal 

Day of thk DxsRASEl 



ntubated on the 2d day of illne--; 

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4 cases? were 
1 case was 

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1 case was intubated on the 9th day of illness 

1 case was intubated on the 14th day of illness 

One case intubated seven years ago has had no illness since. Four 
cases intubated six years ago are in excellent health to-day. One case has 
remained entirely well. One case had enlarged cervical lymph nodes. One 
case had pneumonia one year later. One case had pneumonia and paralysis 
and five years later had a second attack of diphtheria, but no laryngeal 
stenosis. 

Five cases intubated three years ago are in good condition to-day. 
Three had measles and bronchitis after recovery. One has not had a 
day's illness since intubation. One case had a mild attack of croup two 
years after intubation, but did not require reintubation. 

Rachitis seems to play an important part in the causation of laryngeal 
stenosis, just as we know that rickets is met with in laryngismus stridulus. 
Eight cases out of the 10 reported in this series showed some form of 
rickets. 

There seems to be a certain predisposition for the development of 
laryngeal stenosis in children affected with diphtheria who are rachitic. 

Condition of the Throat. — In all of the eases of this - - some form 
of chronic tonsillar or pharyngeal condition was found. Adenoids were also 
seen in 2 of these cases. Whether or no the hypertrophied tonsils seen in 
these cases were present at the time of intubation is not known. The fact 
that S cases out of 10 still showed enlarged tonsils, and 1 case, which makes 
9 cases, reported having had a tonsillotomy performed, proves that hyper- 
trophied tonsils must have menaced the children's health before the diph- 
theria. 

Feeding During Infancy. — It is certainly an interesting fact that all 
of the children in this series were breast-fed. When abnormal conditions, 
as rickets, scurvy, tuberculosis, syphilis. 1 or other undermining disorders 

. then recurring stenosis of the larynx might possibly be provoked by 
such chronic disease. 



1 Read article on "Syphilitic Stenosis of the Larynx:''* in chapter on •'Syphilis/' 
page 720. 



600 THE INFECTIOUS DISEASES. 

These cases of recurring stenosis sometimes require months and, in 
rare instances, years of intubating until recovery takes place. I have seen 
at least 6 chronic tube cases while making my rounds in the wards at the 
Willard Parker Hospital. Intubation has, in America, entirely replaced 
tracheotomy for the relief of acute laryngeal stenosis. Bubber tubes are 
used exclusively for intubation. The old metallic tubes have long ago been 
discarded. Tracheotomy is used as a secondary operation, usually to cure 
"retained tubes." When laryngeal stenosis persists and the patient cannot 
get along without the tube then a tracheotomy is resorted to. 

A very interesting series of papers, describing the above condition, has 
been published by J. Rogers, Jr., under the title of "Postdiphtheritic 
Stenosis of the Larynx" (Eetained Intubation Instruments and Eetained 
Tracheal Cannulas). 

Eogers says : "The commonest cause of postdiphtheritic stenosis neces- 
sitating long-continued intubation is a hypertrophy of the subglottic tissues 
accompanied by a chronic inflammation. The intubation is in no way the 
cause of this, as it occurs irrespective of the operation. Less often there is 
an ulceration, and subsequently a formation of a greater or less amount of 
cicatricial tissue and contraction. This likewise is not the result of the in- 
tubation except in rare, and practically unavoidable, instances. But it 
certainly may follow a tracheotomy, and in a larynx, already chronically 
stenosed, it makes the condition worse, but not necessarily more difficult to 
cure. Exuberant granulations within the larynx apparently do not occur 
with intubation, no matter how prolonged. I should add that in a recently 
published book on 'Tubage et Tracheotomie en dehors du Croup/ by Antoine 
Sargnon, of Lyon, France, a half-dozen more cases of retained tubes are 
cited, in which ulceration and cicatrization are mentioned as causes of the 
stenosis, but without details; and, as I could not find the original refer- 
ences, I cannot well discuss them." 

The frequency of the occurrence of a postdiphtheritic stenosis accom- 
panying intubation is a matter of some interest. Dillon Brown says that 
he has encountered it about once in every 75 or 100 cases. 

C. GL Jennings, of Detroit, with an equally large experience, says that 
he has never met with the severer forms of the difficulty, but that in two or 
three instances he has had to continue the intubation as late as the third 
week after the first insertion, before recovery was complete. His associate, 
Shurley, has never had any trouble with delay in the removal of the tube. 
Galatti, in the article above referred to, states that he had 2 chronic 
stenoses in 31 intubations. He reports Eanke as having had 1 case in many 
hundred; Heubner, 1 in 250, and Bokay 2 in 800. George McNaughton, 
of Brooklyn, says that he has had but few cases in many hundred, and these 
recovered at the latest within several weeks. 

At the Nursery and Child's Hospital of New York City there have been 



IXTl BATION. 



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602 THE INFECTIOUS DISEASES. 

no noticeably prolonged intubations. The Xew York Foundling Hospital 
lias had 6 cases in a total of approximately 500. Investigation of the statis- 
tics at this institution forcibly illustrates the advantages in the use of 
the diphtheria antitoxin. The house physician complained to Dr. Eogers 
that before the introduction of this remedy his predecessors had always 
averaged at least one intubation a week, and thereby obtained much valuable 
experience; but about the time he came into the hospital, the rule was 
instituted that antitoxin should be given to very patient as soon as there was 
any suspicion of diphtheria. The result was that he had never in a year's 
service had a single opportunity to practice intubation on a living subject. 

X umber of Intubations. — In the above series 1 case required four intu- 
bations. Another case required three intubations. The majority required 
but one intubation to effect a cure. 

Kind of Antitoxin Used. — The antitoxin employed at the Willard 
Parker is made at the laboratory under the supervision of Dr. Win. H. Park. 
of the Xew York City Department of Health. 

Method of Intubation Employed at the Willard Parker Hospital. — The 
dorsal method of intubation is the one advocated by Dr. E. G. Bryant and 
Dr. Thos. De L. Burckhalter at the Willard Parker. The advantage 
claimed for it is that we can do without assistants, which in an emergency 
is a great advantage. I have used this method and agree with Bryant that it 
is preferable to the upright position advocated by O'Dwyer. (See Figs. 
184 to 1-;.) 

The dorsal position in intubation is also used and advocated by Cassel- 
berry of Chicago: Carstens of Leipsic is another strong advocate of it. 

Second Series. Children Intubated in Private Practice. — The children 
of this series were seen in consultation with the family physician, excepting 
1 case (Case 11). which was referred to me for personal treatment. They 
belong to the better class of children, which implies better sanitary sur- 
roundings, better food and prompt medical aid when the first symptoms of 
illness are noticed. It was much easier to study this series of cases, as 
the physician in attendance, as a rule, gave me the required data. 

Case X should be excluded in this study, as the child coughed up its tube 
( autoextubation) and died of asphyxia before the physician arrived. Case 
IX must also be excluded, as it was impossible to obtain satisfactory details 
concerning the progress of the case after it recovered from the diphtheria. 

6 cases were intubated S rears ago 

1 case was intubated 7 years ago 
4 eases were intubated 5 years ago 

2 cases were intubated 4 years ago 
2 cases were intubated 3 years ago 
9 cases were intubated 2 rears ago 



INTUBATION. $03 

One of the cases in this scries contracted scarlet fever and died two 
years after intubation. So that 3 cases out of this Beries must be excluded 
Leaving 83 cases from which reports have been received. 

Day OF THE DISEASE. 

1 oa->c v?as intubated on the 1st day of illness 
11 cases were intubated on the 2d day of illness 

9 cases were intubated on the 3d day of illness 

2 cases were intubated on the 5th day of illness 

Number of Intubations Required. 
15 cases required one intubation 

2 cases required two intubations 

3 cases required three intubations 

1 case required four intubations 

2 cases required five intubations 

Length of Time the Tube was Worn. 
1 case 26 days 2 cases 7 days 

1 case 25 days 5 cases 6 days 

1 case 22 days 8 cases 5 days 

2 cases 14 days 1 case 4 1 /- days 
2 cases 12 days 

The average length of time the tube was worn in the above 23 cases was 
9y 2 days or 228 hours. 

Rachitis. — In this second series of cases we are dealing with children 
brought up in excellent surroundings. In the families of the better class 
in New York City the majority of mothers do not nurse their own infants. 
Wet-nurses are not commonly employed. Thus the larger number of these 
children are to-day brought up by bottle feeding. It is, therefore, no wonder 
that in the present series of cases rickets due to malnutrition or inanition 
was very frequently encountered. The susceptibility of the rickety child has 
frequently been mentioned by many authors. In this second series of cases 
rachitis was associated in 19 cases. 

Condition of the Throat. — Not one of these cases had a normal throat 
at the time of the intubation. Adenoid vegetations, enlarged tonsils, and 
chronic rhinopharyngitis were met with in almost every case. When the 
danger of a diphtheritic laryngeal stenosis in a child is considered, then it 
is certainly important to urge the removal of hypertrophied tonsils or 
adenoids if present, and to restore normal conditions in the rhinopharynx 
if possible. Greater attention should be bestowed on the nose, as the most 
fatal cases are those of nasal diphtheria in which general sepsis follows. 

After-effects Resulting from Intubation. — While some physicians have 
reported the existence of a bronchial catarrh during the first and second 
winter months following intubation, the majority of these 16 cases reported 



604 



THE INFECTIOUS DISEASES. 



absolutely normal conditions. Two cases have had pneumonia, in one child 
five years after intubation and in the other child three years after intuba- 
tion. 

One very interesting case in this series was a child (an idiot) 4 years old, seen 
in consultation with Dr. C. Hoffman. This was one of the most trying cases anl 
required five intubations extending over a series of twenty-five days. The child made 
a splendid recovery. Such cases in private practice must be invariably supervised 
by a trained nurse. In this particular case careful feeding in addition to competent 
nursing was the means of saving the child's life. 



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Fig. 192. — Laryngeal Diphtheria. Child 4 years old; mentally deficient. 
Seen in consultation with Dr. C. Hoffmann. (Original.) 



Constant cough or laryngitis lasting many months was encountered in 
•i cases of my series. All in all, there is no case in my series in which a 
distinct bronchial or laryngeal catarrh could be traced to or associated with 
the intubation. 



INTUBATION. i;nr 

Rogers Bays: "As regards the etiology of postdiphtheritic stenos 
the larynx and r itained intubation tubes, the \ tews of the late Dr. O'Dwyer 
are, of course, worthy of the greatest consideration. Nevertheless, I believe 

they are wrong. He maintained that the condition \\;i> the fanll *it her of 
the operator or of the instruments, which means careless or unskilled inser- 
tion, or the use of poorly constructed, and, therefore, improperly fitting 
tubes. Formerly, while he was experimenting with and perfecting his in- 
strument, he sometimes encountered ulcerations and granulation-; and the 
2 cases he reports of granulations at the hase of the epiglottis, where it 
impinged upon the head of the tube, might properly be counted in this 
At all events there is no other record of a similar occurrence from the use of 
the JuirJ-rubber tube as at present made. It must be admitted, however, that 
erosions and ulcerations are possible with a metal tube, as its surface soon 
becomes rough from a deposit of what is apparently calcareous matter. 
But whether ulcerations and subsequent cicatrices may not be thus produced 
has very little to do with the matter, as they do not seem to be the usual 
cause of the stenosis in the reported cases. . . . And it is important, 
from a medico-legal aspect, as well as for the sake of intubation, to show that 
neither the operator nor tube, ordinarily, has anything to do with a possible 
postdiphtheritic stenosis. It is granted that lacerations and serious per- 
manent damage to the larynx can, of course, be inflicted by extreme lack of 
skill or care ; but to claim that this must have happened in all, or even some, 
of the cases of retained tube is not borne out by the facts. A certain amount 
of traumatism is necessarily inflicted at every intubation, and if, by any 
chance, a chronic stenosis follows, the traumatism is always blamed for it. 
That this is wrong, at least in the average case, is proved to my mind by the 
pathology of the condition. It is the same whether the stenosis follows intu- 
bation or a primary tracheotomy ." 

Causes of Recurring Stenosis. — Emil Kohl, in his inaugural address at 
Zurich, in 188-1, described very fully the pathological condition of the 
larynx in cases of chronic postdiphtheritic stenosis with retained tracheal 
cannula. This article demonstrates most conclusively that not the least 
frequent cause of the difficulty is a chronic hypertrophic, subglottic 
laryngitis, a chronic thickening of the soft parts between the vocal cords and 
the lower border of the cricoid cartilage. The hypertrophy of the soft tissue 
was so marked that respiration, except through tracheal fistula, was impos- 
sible. These cases, of course, had never been intubated; and, therefore, 
the chronic inflammation within the larynx cannot be charged to the irrita- 
tion or traumatism consequent upon the insertion or wearing of an intuba- 
tion tube. 

Another and more frequent cause of the stenosis was shown to be 
granulations and cicatrices in the neighborhood of the tracheal wound or 
cannula. And the nearer the cannula was to the vocal cords the worse were 



606 THE INFECTIOUS DISEASES. 

these complications. The vicinity of the upper end of the wound was more 
prone to granulations and cicatrices than the lower, as the upper end gener- 
ally involved or was close to the larynx, where the mucous membrane is 
more loosely attached than below. This bears upon the cause of the stenosis 
described in some of the reported cases of retained tubes which have finally 
been tracheotomized. If the tracheotomy has existed long enough, it, and 
not the original intubation, may have given rise to the cicatricial tissue. 

Incidentally, it may be noted that the number of devices described by 
Kohl for remedying a postdiphtheritic stenosis will illustrate the difficulties 
in the way of successful treatment other than by intubation. 

In speaking of the operative treatment of stenosis of the larynx follow- 
ing intubation and tracheotomy, Arthur B. Duel says: "The important 
points to remember: (1) About 1 per cent, of all patients intubated for 
acute laryngeal stenosis will f retain J the tube. (2) The cause of the reten- 
tion is due, in the majority of cases, to chronic inflammation of the ihtra- 
laryngeal mucous membrane and hypertrophy of the subglottic tissues, and 
is not, as has been generally supposed, the result of granulation, ulceration, 
or cicatricial bands. (3) Autoextubation in these cases is the rule, and 
adds greatly to the danger where an experienced intubator is not at hand. 
As a result of this a large number of such cases are tracheotomized for safety. 
(4) Where high tracheotomies are done, cicatricial bands are almost certain 
to form in the trachea or lower part of the larynx above the tracheotomy 
wounds." 

The points in treatment which should be emphasized are: (1) The 
largest sized tube possible should be inserted, under an anaesthetic. In case 
of contraction, rapid dilatation should be done by beginning with the small 
sizes and working up to the large special tube, which is to be left in place. 
This special tube should be as large as can be inserted, and the constriction 
below the neck only 1 / 32 inch smaller than the retaining swell. (2) This 
tube should be left in, undisturbed, for six weeks at least. It should then 
be removed, and, if a cure has not been accomplished, it should be replaced 
for six weeks longer. 

To illustrate the above the following case may be cited : — 

Child B., 2 years old, was seen by me in 1895, in consultation with Dr. 
McConville, of Brooklyn. The child had had a severe pharyngeal, tonsillar and 
laryngeal diphtheria. The temperature was 101° F., pulse 140, respiration labored. 
Child cyanotic. I intubated with a No. 2 metal tube, which immediately relieved 
the laryngeal stenosis. The general condition of the child improved greatly and 
three days later I was requested to extubate. Several minutes after extubation 
marked laryngeal stenosis recurred so that a second intubation was necessary. The 
child's condition again improved, and when normal conditions prevailed, in about 
four days I was again requested to extubate. Thus the child was intubated and 
extubated every four days for a month. As the family were unable to retain the 
services of a competent trained nurse, and as the child required frequent medical 



IN'Tl BATK .1.7 

supervision, the ease was transferred t<> the Qouverneai Hospital. Dr. I 

I this ease as he does all of hi> "retained tu by introducing the 

largest sized mix? that ran \>v worn, and allowing the tube t<> remain in situ four, 
fire or six weeks before extnbating. After one month of this treatment 1 w;is 
informed that extubation permanently relieved the condition and the child was dis- 
charged from the hospital cured. 

Paralysis of the Vocal Cords. — Very many cases have been reported In- 
competent observers on both sides of the Atlantic. In America, Waxham, 
Rosenthal^ Engelmann. myself and many others: in Europe, von Bokay. 
Trump. Egidi, Galatti. Massei. and Escat. 

Intubation in Hospital Practice. — There is a decided difference be- 
tween intubation in a hospital and intubation in private practice. In the 
Willard Parker Hospital. New York, there are always several physicians 
ready to intubate at a moment's notice. I have seen more than one case of 
mild stenosis, treated with antitoxin and careful dietary, get well without 
intubation. Haste is not necessary, and each case is carefully treated. 
When intubation was not regarded as sufficient relief I have seen several 
cases tracheotomized by the assistant resident physician. Dr. Beery, with 
excellent results. 

Intubation in Private Practice is an entirely different matter. 
Johann von Bokay in his review regarding intubation published in the 
"Transactions of the Section on Diseases of Children,"" held at Hamburg, 

. honors me by the following quotation 1 : " Auch halte ich das Vorgehen 
von Louis Fischer, des hervorragenden intubators aus Xew York, fur 
unrichtig. der sagt : Ich niaehe es mir zur Eegel — wenn ich sicher den 
Xaehweis liefern kann, dass es sich um eine Diphtherie handelt und ich das 
Yorhandensein des Klebs-Loffler-Bacillus constatirt habe, die intubation 
sofort vorzunehmen, wenn sich d>ie geringste Stenose zeigt.*' 

While his statement is partly true, it does require a slight modification. 
When a mild case of laryngeal stenosis is encountered in private practice. 
then judgment must be used regarding the time for intubation. The 
points to be considered are: the distance at which the patient lives, the 
amount of diphtheritic infection that we are dealing with, and the circum- 
stances of the people in which the case occurs. If the child is fortunate 
enough to be under the observation of a competent nurse, who can recognize 
the slightest increase in the stenosis, watches the condition of the heart, and 
calls the physician the moment the slightest danger arises, then the condi- 
tions are most satisfactory and we can wait with intubation, otherwise we are 
compelled to intubate when slight evidences of stenosis appear, i" do not ad- 
vocate intubation the moment stenosis exists. In Case XXI of my series of 
private cases above reported, seen in consultation with Dr. Harry Weir- 



: My rule is to intubate when the slightest steno-i< exists, provided the clinical 
diagnosis of diphtheria has been verified by the bacteriological diagn 



60S THE INFECTIOUS DISEASES. 

the stenosis of the larynx was treated by an injection of antitoxin, the child 
placed under the care of a competent trained nurse with detailed instructions 
regarding progressive symptoms. Twelve hours later, when the stenosis wi- 
ld severity. I was summoned hurriedly to intubate. In this case the 
child wore the tube six days, and required but one intubation to complete the 
cure of the stenosis. In America the majority of intubated cases occur in 
private practice. Yon Bokay states that according to Jacobi, only 5 per 
cent, of diphtheritic laryngeal stenosis are treated in the special (Willard 
Parker) hospital. The rest. 95 per cent., occur in private practice. 

The smooth rubber tube with or without metal lining is now generally 
used for the relief of laryngeal stenosis. Smooth rubber tubes, with a re- 
taining swell, the advantage of the same over the metal tube in not having 
calcareous deposits after being worn for weeks is certainly noteworthy. The 
corrugated rubber tubes which* were introduced by me several years ago have 
certainly served me very well in many cases of "retained tube."' 

The following case occurred in the practice of Dr. A. TV. ZSTewneld. The child 
was about 4 years old, and had suffered for several years with hypertrophied. tonsils 
and adenoid vegetations, in addition to chronic pharyngitis. The family physician ad- 
vised the parents to have the throat operated owing to the danger of infection with 
diphtheria. This prophylactic measure was not carried out. I saw the case on the 
second day of illness, in consultation with Dr. Xewheld. and found diphtheria in- 
volving the pharynx and tonsils which spread very rapidly to the larynx. The same 
day intubation was required to relieve a severe stenosis. The stenosis was so 
severe when I saw the child, and the pulse so weak, that it required a rapid intro- 
luction of the tube to afford relief. An injection of 3000 units of antitoxin was 
given. Three days later a second injection of 3000 units was made: so that 6000 
units were injected in all. There was recurring stenosis when the tube was re- 
moved. It was necessary to intubate within ten minutes. Extubation was per- 
formed once every five days, and reintubation was necessary a few minutes to one- 
half hour after removing the tube. Rubber tubes only were used in this case. After 
the second intubation an alum gelatine film was used on the tube. 

After the third intubation it was deemed necessary to use a corrugated tube 
dipped in a solution of hot gelatine containing 3 per cent, of iehthyol and alum. 
This tube was worn about five days. After the extubation the child breathed well 
for about one hour without a tube. A mild form of stenosis was noticed and it 
was deemed safe to reintubate with an iehthyol aluni gelatine film on a Xo. 4 corru- 
gated rubber tube. This tube remained about six days and was then removed. 
Stenosis did not recur and the case was discharged cured. Later on the adenoids 
and hypertro phied tonsils were removed and the child has been well since. 

Cc , — All the children in both these series that recovered had 

been breast-fed. This form of feeding must have had an important bearing 
on their bony development as well as their muscular structure. 

No i con. gli which could be attributed to the wearing of the tube 

was encountered. It was presumed by me at the outset of my investigation, 
that I might meet with a series of cases of chronic laryngitis, chronic 
tracheitis and chronic bronchitis, dating back to the intubation. TTe know 



INTUBATION. 609 

that pressure of the tube has frequently caused decubitus; hence, it is pre- 
sumed that an inflammatory process tnighl be invited from the wearing of 
the tube. Comparing an equal number of children of the same age and 
development who never suffered with diphtheria, nor were Intubated, n was 
found that they suffered with pneumonia and other infectious diseases in the 
same proportion as children in my series of cases. This would seem to be 
a splendid argument in favor of intubation, as it shows two important 
points : — 

First — The tolerance of the larynx to a tube for many weeks, one of 
my cases having worn a tube twenty-six days, another case twenty-five days. 

Second. — That a properly fitting tube constructed of rubber leaves no 
evidence of chronic inflammation directly traceable to the tube. In every 
one of my cases I questioned carefully if any catarrh originated from, or 
could be associated with, the wearing or removal of the tube, and received 
negative replies. 

Equally interesting was it to study the contour of the thorax and to 
see if the development of the thorax suffered by reason of these children 
wearing tubes. 

In spite of the fact that the large majority in the first series as well as 
in the second were decidedly rachitic, no deformity of the chest due to imper- 
fect oxygenization could be attributed to the effects of the intubation tube. 
An etiological factor and one on which a great deal of stress has already 
been laid, is that 90 per cent, in my first series of cases suffered with chronic 
throat disease in some form, such as hypertrophied tonsils, chronic pharyn- 
gitis, or adenoids. In some all of the above conditions were apparent. 

It is safe to presume that chronic throat disease invites infection, and I 
believe that there is a direct relationship between the seed and the soil. If 
children's throats are in a normal condition, then the risk of infection is 
reduced to a minimum. It is our duty, therefore, to urge all mothers to 
have diseased conditions removed, and thus try to prevent the infection of 
diphtheria, which is certainly a serious condition. 

Recurring Laryngeal Stenosis Following Intubation 
and Decubitus. 

Etiology. — This condition is primarily caused by forcibly pushing a 
tube into an cedematous or infiltrated mucous membrane. O'Dwyer says 
that it is caused by using a tube that is too large for the lumen of the 
larynx; usually in the hands of inexperienced operators. Metallic tubes 
that have been worn for a long time contain large calcareous deposits — the 
latter are due to a deposit of lime salts contained in the diphtheritic mem- 
brane — and when removing such a tube during extubation, the mucous mem- 
brane is easily lacerated, and thus ulceration is caused thereby. One of the 
most important papers given to the profession was read by the late 



610 THE INFECTIOUS DISEASES. 

Joseph O'Dwyer. 1 In his paper entitled "Ketained Intubation Tubes" he 
says: "The cause of persistent stenosis following intubation in laryngeal 
diphtheria can be summed up in the single word 'traumatism.' Paralysis 
of the vocal cord may possibly furnish an occasional exception to this rule." 

Thus an injury to the larynx can be done by a tube that does not fit; 
it may result from an imperfectly constructed tube, or from a perfect tube 
that is too large for the lumen of the larynx, although proper for the age, 
or from a tube that is perfect in fit and make if not cleaned at proper inter- 
vals. O'Dwyer states that the seat of the lesion that keeps up the stenosis 
is just below the vocal cords in the sub-glottic division of the larynx, or that 
portion of the organ bounded by the cricoid cartilage. Exceptions to this 
rule result from injury produced by the head of the tube on either side of 
the base of the epiglottis, just above the ventricular bands. The reasons 
given by O'Dwyer for the existence of the stenosis at this particular portion 
can best be explained by the following : — 

Pathology. — Anatomically, normally, there exists a constriction in the 
cricoid region. When the mucous membrane infiltrates or gets oedematous 
it swells to such an extent and only toward the center, as the outside is sur- 
rounded by cricoid cartilage; and while swelling toward the center, me- 
chanically impedes respiration and thus calls for mechanical relief, i.e., intu- 
bation. CTDwyer states that if a tube is forced into the larynx in a case of 
this kind, ulceration and sloughing of the tissues is inevitable, and in some 
instances necrosis of the cricoid cartilage can result from interference with 
the circulation. Our only safeguard in preventing too much mechanical 
injury as in the condition above cited is to introduce "a tube of small 
caliber." 

In the early stage of this form of cases the dyspnoea returns slowly; 
sometimes several days, or in some instances only a few hours, may pass 
before the former condition of laryngeal stenosis is recognized and the neces- 
sity for the introduction of a proper tube is demanded. 

When the dyspnoea returns slowly, it means that the lining membrane 
of the larynx cannot swell while the tube is in position because it is com- 
pressed between the tube and the cartilage. It requires some time for the re- 
appearance of the oedematous tissue, which drops into the chink of the 
glottis and obstructs the respiration, the latter condition being mechanically 
prevented as long as the tube was in situ. Exceptional cases have been re- 
ported where. granulation tissue springs up from the antero-lateral aspects of 
the larynx just above the ventricular bands. O'Dwyer states that the 
origin of this growth is a slight ulceration or erosion of the mucous mem- 
brane at the points corresponding to the greatest transverse diameter of the 
shoulder of the tube from the pressure exerted during the act of swallowing. 

Paralysis of the Vocal Cords, although known to exist, is very hard to 

1 American Pediatric Society, at Washington, May 6, 1897. 



INTUBATION. 



611 



diagnosticate without a proper Laryngoscopy examination. Like other 
forms of paralysis it conies very late in the course of the disease, and if, after 
wearing an' intubation tube for a short time, laryngeal stenosis recurs, it is 
safe to assume that paralysis of the vocal cords is not the cause of the im- 
mediate recurring stenosis.' 




Fig. 193. — Case seen in consultation with Dr. S. M. Lansdmann. Diph- 
theria. Laryngeal stenosis requiring intubation. Normal conditions and 
extubation on the fifth day. Two days later, on the seventh day of illness, 
a sudden high fever, due to over-feeding, required diet and calomel. Case 
recovered. (Original.) 

How can we prevent recurring laryngeal stenosis in ordinary mem- 
branous diphtheria? Every tube must be introduced in the gentlest manner 
possible, the slightest force exerted will lacerate the tissues. It is a wise 
rule to remove the tube every five days ; according to O'Dwyer, tubes should 
be removed at the end of five days to avoid irritation from calcareous de- 
posits. These deposits will only form on metal and not on the rubber tubes. 
This has been pointed out by most writers, and is borne out by experience. 



612 THE INFECTIOUS DISEASES. 

Treatment. — Intra-laryngeal Medication: When laryngeal stenosis re- 
curs and it is necessary to intubate several times, local medication of the 
larynx may do good. This is especially true if we are dealing with ulcer- 
ations caused by the end of the tube during deglutition. Ulcerations caused 
by the pressure of the tube are the ones known as decubitus ulcerations. 
They most frequently result from irritations caused by the calcareous de- 
posits on the metal tubes. Such calcareous deposits produce irritation and 
finally ulceration. 

CTDwyer, many years ago, advocated the use of a gelatine film contain- 
ing such medications as ichthyol or alum. The writer has for some years 
past used with a varying degree of success certain formulae which have 
served him quite well in certain cases. The following method of coating 
tubes is recommended : For a child 2 years old, take a 1 year size tube and 
have the same coated with the following : — 

French gelatine, shredded , 2.0 

Glycerine 2.0 

Water 10.0 

Ichthyol 1.0 

Dissolve over a water bath and immerse the tube, being careful not to close the 
ends. Place the tube on pins stuck through a piece of cardboard and allow to dry. 
Should too thick a layer of gelatine have been acquired, hold near the spout of the 
water bath and allow the steam to play on the tube, causing the excess to drip off. 

If we have fever and a very rapid and feeble pulse, and the general 
circulation is poor, with cold extremities, then tonics, such as iron and 
strychnine, or restoratives, such as codliver-oil and malt extract, should be 
ordered in addition to concentrated foods. Thus by restoring the normal 
condition and by assisting the nutrition we can hope for the repair and heal- 
ing of superficial lesions. It frequently happens that in spite of "a medi- 
cated tube," such as above described, stenosis will recur. In order to guard 
against possible calamities, it is wise to have another tube with its proper 
medicated gelatine film ready to be used if occasion requires it. 1 

False Passage. — Eepeated forcible attempts at intubation will lacerate 
the tissues. It is not infrequent to enter the ventricles of the larynx, pro- 
ducing a false passage by such forcible attempts at intubation. If a false 
passage has been produced, then laryngeal stenosis will not be relieved, and it 
is much wiser, if an expert intubator cannot be found, to immediately resort 
to tracheotomy. The great danger of collapse due to heart failure must 
always be remembered, hence it is advisable that the operation, be it intu- 
bation or tracheotomy should be done quickly thus lessening shock. 



1 A complete paper on "Intubation with Clinical Results of Intra-laryngeal Medi 
cation" was published by me in Archives of Pediatrics, February, 1904. 



EXTUBATION. 



613 



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Fig. 194. — Temperature Chart from a Case of Laryngeal Diphtheria. 
Excellent Result of Intubation and Antitoxin. Doubtful Prognosis. Re- 
covery. ( Original. ) 



EXTUBATION. 

How to Extubate. — First step in the operation : place gag in position ; 
locate the tube with the left index finger; guide the extractor along the 
finger until the beak enters the lumen of the tube. Second step in the oper- 
ation: depress the handle of the extractor to hold tube firmly, and with- 
draw the tube slowly. (See Figs. 186 and 187.) 

When to Extubate. — Five days is a fair length of time for the tube 
to be left in the larynx. The following rules have served me best in a 
very large experience in hospital and private practice: — 

Let the child's condition be the guide as to when to extubate. My 
advice is to leave the tube in the larynx at least four days, then remove the 
same. 

The question to be considered is, can the child undergo the shock of 
extubation, and, if need be, reintubation. 



614 THE INFECTIOUS DISEASES. 

If the temperature is over 100° P., and the pulse-rate is small, rapid, 
and over 150, it is better to wait with the extnbation. 

A rubber tube left in the larynx does not have calcareous deposits as 
we find them on the metal tubes, hence there is no danger in leaving a 
rubber tube in situ for several weeks. 

If the tube is plugged with mucus or membrane it may be necessary to 
remove the tube and clean it. A rattling or crowing sound in addition to 
laryngeal stenosis usually indicates this condition. 

At the YVillard Parker Hospital there is no definite rule as to the 
number of days a tube remains in the larynx. Individual conditions 
govern the time of extubation. In some cases tubes are removed after 
forty-eight hours. The severity of the cases admitted to the hospital and 
the complication must be taken into consideration. Uncomplicated cases 
may be extubated any time between the third and seventh days when the 
oedema of the larynx subsides. In a few instances the child expels the tube 
without having recurring stenosis. This auto-extubation is occasionally 
seen; it is Xature's method of removing a foreign body after the subsidence 
of the inflammatory condition. 

A very interesting observation recently made at the TVillard Parker 
Hospital by Dr. William Studdiford is that a child with otitis does not do 
as well in extubation as one whose ears are normal. It seems quite evident 
that reflex disturbance caused by severe pain may finally result in spasm of 
the glottis. A good point therefore is to have the ears examined before 
attempting extubation. 

Antispasmodic Treatment. — Before resorting to extubation, it has been 
my rule to give a large dose of bromide of sodium combined with chloral hy- 
drate at least six hours before extubating. At the Willard Parker Hospital, 
morphine is sometimes used hypodermic-ally in doses of 1 /' 16 to y s of a grain, 
depending on the age and strength of the child to be extubated. This 
method is very successful, especially when all evidence of diphtheria has 
passed, and it is simply, necessary to relieve peripheral irritation to avoid 
spasm. 

Choice Betweex Ixtubatiox axd Tracheotomy. 

In cases where operation is indicated it may be said that intubation has 
steadily grown in favor, and its advantages, when it is indicated, are so 
obvious as to require no recapitulation here. On the other hand, conditions 
are sometimes present that render intubation impracticable or inadmissible, 
or at least render tracheotomy preferable. It is therefore desirable 
to keep clearly in mind the factors that determine the choice in favor 
of one or the other of these operations. This subject has received con- 
sideration in a study, by Drs. George Alsberg and Sigmund Heimann, of the 
cases of diphtheria, to the number of -±033, observed at the Kaiser und 



TRACHEOTOMY. 615 

riii Friedrich Kinderkrankenhaus, in Berlin, for the ten years from 
Afl a result of this analysis it is concluded that operative in- 
tervention in cases of si :. sis of the larynx of slight and moderate degree 
should be obviated as far as possible by means of antitoxin and the employ- 
ment of sprays. Primary intubation is indicated in all cases of stenosis of 
the larynx of severe degree, in which, so far as the clinical picture makes it 
appear possible, a cutting operation can be avoided. Primary tracheotomy 
is indicated in the presence of asphyxia and collapse, of pneumonia,, of severe 
heart disease, of paralysis of the palate and diaphragm, of profound anatomic 
changes in the pharynx, as well as marked tumefaction of the entire pharyn- 
geal structures when necrotic. 

Secondary Tracheotomy is indicated when the symptoms of ster - - 
persist in marked degree with the tube in place, providing its lumen is not 
occluded, when pneumonia supervenes, and when paralysis of the palate 
and diaphragm supervenes. Intubation is not recommended in nursing in- 
fants by some writers on account of the diminutiveness of the parts and of 
the narrow lumen of the pharynx, but especially on account of the inc: 
difficulty in feeding from the presence of the tube, which at this time of 
life is of vital importance. My personal experience is just the reverse, and 
my results have been excellent. 1 - 

Teacheotozniy (In Acute oe Subacute Laetxgeal Stenosis). 

If laryngeal stenosis persists in spite of intubation, then secondary 
tracheotomy is indicated. When extensive cedema of the larynx exists, in 
which case intubation fails to relieve, tracheotomy may be required. I have 
frequently met surgeons who were well posted on tracheotomy, but were not 
familiar with the delicate modus operandi of intubation. 

If laryngeal stenosis threatens life, and the physician is not acquainted 
with the method of intubation, then by all means perform tracheotomy, 
rather than risk "experimental intubation,*' 

When emergencies arise they should be met by quick action. An in- 
teresting case of suffocation due to laryngeal stenosis was told to me by 
my friend, Dr. George F. Shrady : — 

A child suffering with croup suddenly collapsed and was thought dead, when 
Dr. Shrady. in the emergency, took a razor which was handy and made an incision 
into the trachea. He used a bent hairpin instead of a tracheal dilator. The child 
breathed as soon as oxygen was admitted. The case recovered. 

I have seen cases successfully tracheotomized by Dr. Throne and Dr. 
Beery, and have also assisted Dr. Burckhalter in performing tracheotomy at 



x See case of Baby R. in the practice of Dr. Kahrs, ''Intubation in Private 
Practice." 



616 THE INFECTIOUS DISEASES. 

the Willard Parker Hospital, when intubation did not relieve laryngeal 
stenosis — as in subglottic cedema. 

The Operation. — Anaesthetic: If time permits, a few drops of chloro- 
form should be given. If septic stupor exists then no anaesthetic should be 
given. 

The high operation * , 'tracheotomie superieure"* in which the incision is 
made in the upper portion of the trachea is preferred to the lower operation 
advised by Trousseau, known as "tracheotomie inferieure." 

The upper portion of the trachea is quite superficial and it is best to 
make an incision exactly in the median line, at least two inches in length. 
It is important to remember that the branches of the inferior thyroid veins 
are immediately under the place chosen for the operation, hence the parts 
must be carefully dissected with a blunt instrument, such as the back of a 
scalpel, until the trachea is reached. If there is severe bleeding the veins 
should be seized with a forceps unless emergency demands rapidity of action. 
The dissection should be continued until the trachea is reached. When there 





Fig. 195. — Silver Trachea Cannula 

used in tracheotomv. _ 

-Hard Rubber Trachea Cannula. 

is considerable oozing of blood, and our view is thus obstructed, we must 
remember to keep in the center of the throat, which invariably brings us to 
the rings of the trachea. By placing the finger in the wound we 
will feel the respiratory movement of the trachea. When the trachea is 
reached it should be hooked up with a tenaculum and an incision made large 
enough to admit the tracheotomy tube. The rush of air, so-called tubal 
sound, characteristic of intubation, is also heard when tracheotomy is 
properly performed. 

After-effects of the Tracheotomy Tube. — The presence of the tube in 
the trachea invariably excites cough. This expels loose membranes 
and other viscid accumulations. High fever sometimes follows this 
operation, although as a rule the temperature will only reach 101° or 
102° F. 

The pulse-rate should be carefully observed: a gradually increasing 
pulse-rate during the first three days after the operation is a very bad sign. 

Complications. — Broncho-pneumonia and nephritis are to be feared, for 



CHRONIC DIPHTHERIA. 617 

they frequently terminate fatally. The treatment of complications is the 
same as though the disease existed independent of the operation. 

After-treatment. — Careful aseptic methods must be the rule from the 
moment the child's stenosis is relieved. The infection of the wound will 
always be an added source of danger. As the majority of cases of trache- 
otomy will be performed for extensive pseudomembranous stenosis, we must 
remember that septic diphtheria per se may cause death independent of the 
added danger incident to the opening of the trachea. All oozing of blood 
must be checked; pressure with sterile gauze saturated with Aionsell's solu- 
tion has served me well. I have also used gauze dusted with a powder con- 
sisting of: — 

IJ Europhen 7 parts 

Alum 3 parts 

To Check Hcemorrhage. — The local application of adrenalin solution, 
1 to 5000, is very valuable during the operation. 

The internal cannula should be removed, and cleaned every two or three 
hours, wiped dry and replaced. In rare instances it may be necessary to 
cleanse the cannula less frequently. This can best be determined by 
watching the respirations and instructing the trained nurse as to when the 
caliber of the tube requires cleansing. Xoisy, rattling sounds due to the 
presence of mucus in the tube do not necessarily mean that the cleansing of 
the cannula is urgent, if the child is quiet or asleep. If the child is restless 
and turns its head from side to side, and usually mucus rattling is heard in 
addition, then it is an indication for cleansing the tube. 

Cleansing the ~SYound. — Each day following a tracheotomy, it is advisa- 
ble to place the child on the operating table, withdraw the tracheotomy tube 
and replace it with a new one. 

A writer states that "after the second or third removal the larynx 
should be examined to see if it is free and there is no further use for the 
cannula." My experience with tracheotomized cases has not been as good as 
that, for rarely have I seen a tracheal cannula that could be dispensed with, 
although antitoxin was administered, in less than seven to twenty-one days. 
The severity of my cases may account for the difference in experience. At 
times, in spite of the greatest amount of care, even in the hands of experi- 
enced operators, cicatrices of the trachea resulting in permanent contraction 
or exuberant granulations at the site of incision will require the continued 
use of the tracheotomy tube, as in cases described in the chapter on "Intuba- 
tion," known as "retained tube cases." 

Chroxic Diphtheria. 
There are two varieties which characterize this condition. 
The first form is simply the continuation of an acute attack of 
diphtheria, running a prolonged course. Second, a chronic form in which 



618 THE INFECTIOUS DISEASES. 

symptoms of pseudo-membranous rhinitis exist and which may be present 
months or years. 

In the prolonged type previously mentioned, fever, glandular swelling 
and general systemic disturbances mark the beginning of the attack. In 
the latter type the febrile manifestations and general constitutional dis- 
turbances are totally absent. 

Diagnosis. — The clinical picture of the chronic type of diphtheria 
narrows down to two distinct features. First, the presence of pseudo-mem- 
branes in the nose, pharynx, or lar}Tix, for months or years. Second, the 
persistence of the Klebs-Loeffler bacillus. Third, the marked absence of 
general constitutional disturbances. 

Neisser, v. Behring, Walb, and more recently Xewfield, 1 describe this 
form of diphtheria. He found that a series of cases of rhinitis atrophicans 
and ozasna showed Klebs-Loeffler bacillus in addition to the ozaena bacillus. 
I have met with cases of this prolonged type of diphtheria which clinically 
resembled syphilis. 

Prognosis and Course. — Such cases require very careful observation and 
a very guarded opinion should be expressed as to the length of time that 
the condition will last. Xot infrequently tuberculosis or some form of 
chronic broncho-pneumonia may follow with fatal result. In a case of 
chronic diphtheria extending over seven months, which was complicated 
by entero-colitis during midsummer, the result was fatal. 

Isolation. — The presence of the Klebs-Loeffler bacillus demands the 
strictest isolation from all healthy persons. The virulent nature of the 
Loeffler bacillus should be remembered. All children suffering with en- 
larged tonsils or those having adenoid vegetations should be carefully 
guarded against exposure to a case of this kind, as they are more prone 
to infection than those having healthy throats. 

Treatment. — If we are dealing with a subnormal condition, the system 
must be built up with codliver-oil in addition to a concentrated diet, such as 
eggs, cereals, and broths. The most valuable drug, undoubtedly, is iron. 
The tincture of the chloride of iron. 10 to 30 drops, three times a day. or 
of tener, is very useful for its local as well as its systemic effect. I administer 
iron regardless of its constipating tendency, for weeks and months. 

Locally, a bichloride spray or a spray of DobelL's solution can be used 
three or four times a day. If after several weeks of persistent treatment 
no benefit results, then a decided change of air, such as a trip to the seashore 
or to the mountains, will assist in the cure of the patient. 

Diphtheeoid. 
This term we owe primarily to the French. It was introduced into the 
German literature by Professor Baginsky, and after him, by Escherich. 



1 D. Med. Woch., May 12, 1904. 



PSEUDO-DIPHTHERIA. 619 

This disease is mused by as infection resulting from a serii mis, 

chiefly Btreptococci 01 staphylococci. It is a disease which differs entirely 
from diphtheria. It is not a serious disease. There are no Klebs-Loefller 
bacilli present. The usual evidences of systemic infection are absent. The 
child shows the clinical evidences of an infection in a milder form than is 
usually met with in diphtheria. The prognosis is good. The treatment 
should be directed toward restoring the normal condition of the body, and 
hence the saccharated carbonate of iron given in 5 to 10-grain doses, three 
or four times a day, is very useful. Locally, an astringent antiseptic gargle, 
consisting of equal parts of Dobell's solution and of warm water, to be used 
every hour for gargling, or a 1 to 5000 bichloride of mercury solution is 
very useful. Xormal salt solution is also recommended. 

The nutrition of the body will be the means of restoring the functions 
to their normal state. It is important, therefore, to feed in regular inter- 
vals, milk, soup, broth, and eggs, if they can be assimilated. If the child 
is a bottle baby or a nursling at the breast, then a smaller quantity of food 
should be given, and if the same is not taken by the mouth then rectal ali- 
mentation will be urgently called for. It is wise to isolate e^ch and every 
form of diphtheroid affection and thus prevent the possibility of the trans- 
mission of this infection. 

Pseudo or False Diphtheria. 

Under this general title are included all cases of pseudo-membranous 
or exudative inflammation of the mucous membranes in .which the diph- 
theria bacilli are absent. 

Since Loeffler, in 1889, first described a class of pseudo-membranous 
inflammations of the throat in which the diphtheria bacilli were absent 
and cocci present, it has been established that a certain portion of the 
inflammations of the respiratory mucous membranes, which closely re- 
semble the less characteristic cases of diphtheria, are not due to the diph- 
theria bacilli, but to cocci, especially to streptococci. 

It has been found that streptococci are commonly present in the throats 
of healthy persons, or at least in the throats of persons living in large cities, 
and that other forms of cocci, especially the pneumococci and staphylococci, 
are apt to be associated with them. 

These germs seem to live in the throat without creating any disturb- 
ance there, so long as the mucous membranes are healthy; but under cer- 
tain conditions, as when the mucous membrane has been made vulnerable 
by exposure to cold or other deleterious influences, or by the poison of scar- 
let fever, measles, or some other disease, the streptococci, alone, or asso- 
ciated with other cocci, are able to attack the mucous membrane and to 
cause an inflammation. This may be of any degree of intensity, from a 
simple inflammatory hyperemia to an inflammation with an extensive 



620 THE INFECTIOUS DISEASES. 

production of pseudo-membrane or with ulceration. Such inflammations 
when associated with the formation of pseudo-membrane are known as 
pseudo-diphtheria. The exudate or pseudo-membrane in pseudo-diphtheria 
is usually confined to the tonsils, but other parts, such as the larynx, 
pharynx, and nostrils, may be invaded. 

It has been found that the percentage of mortality in these cases is far 
less than in diphtheria, and that the disease is seldom, if ever, commu- 
nicated to others. 

Age and Mortality in False or Pseudo-diphtheria. — To compare the 
mortality and the communicability of false diphtheria with that of true 
diphtheria, 450 cases of the false were carefully investigated by sanitary 
inspectors detailed for this work. 1 These cases comprised 300 occurring 
in the fall months, and 150 occurring in the following spring. The cases 
were taken in consecutive order, and are believed to be average cases. 

In the 450 cases investigated there were 11 deaths, or about 2 1 / 2 per 
cent, mortality. Of the -150 cases, 42 were complicated with scarlet fever, 
and of these 12, 4 died. In 6 of the 450 cases, measles occurred as a com- 
plication, and these all recovered. Of the 2 deaths which occurred among 
the adults, 1 was of a man of TO years, who was suffering from a serious 
valvular lesion of the heart, and the other was a young adult female, who 
died of septicaemia. 

The statistics gathered of the location of the disease in the true and 
false cases are of special interest. There were 286 of the cases examined 
in which the disease was entirely or chiefly confined to the larynx or bronchi, 
and of these 283 were in children. In the cultures of 229 of the 
286 characteristic Loeffler bacilli were found, and the cases were thus 
proven to be true diphtheria. Of the 229 cases in which the Loeffler bacilli 
were found, 12 T showed no pseudo-membrane or exudate above larynx, 
while in the remaining 62, although the larynx was mainly involved, there 
was also some membrane or exudate present on the tonsils or in the pharynx. 
In 57 out of the 286 examined, no diphtheria, bacilli were found, but in 17 
of these the cultures were unsatisfactory. Excluding the IT doubtful 
cases, there were 40 cases of pseudo-diphtheria in which the diphtheria 
bacilli were certainly absent. The disease was confined to the larynx or 
bronchi in 27 out of 40, while more or less exudate or membrane was 
present on the tonsils or in the pharynx in 13. 

The Proportion of Cases of Suspected Diphtheria which upon Exami- 
nation Prove to be True Diphtheria. — "As soon as careful investigation 
had demonstrated it was possible, with proper precautions, to separate by 
bacteriological examination the cases of the true from those of the false 
diphtheria, large numbers of cases suspected to be diphtheria were exam- 



1 Bulletin of the New York Health Department. 



PSEUDO-DIPHTHERIA. 621 

ined bacteriologically. The reports from hospitals in which all cases of 
suspected diphtheria were examined, arc of special interest as showing the 

proportion o\' eases o[' true to false diphtheria. The results from these hos- 
pitals are all the more valuable because they come from all parts of the 
various cities in which the respective hospitals were located, and hence 
special local conditions were not likely to greatly influence the result ob- 
tained. Thus, Baginsky, in Berlin, found the diphtheria bacilli in 120 
out of 244 suspected cases; Martin, in Paris, 126 out of 200; Park, in 
New York, 127 out of 244; Janson, in Switzerland, in 63 out of 100, and 
Morse, in Boston, in 239 out of 400. Thus, from 20 to 50 per cent, of the 
eases sent to diphtheria hospitals did not have diphtheria. 

"If we examine the reports of examinations made under some special 
conditions, as during an outbreak of some contagious disease in a hospital 
for children, we find the results may differ in a striking manner. 

"Thus, in 1889, Prudden made bacteriological examinations of 24 
fatal cases of pseudo-membranous inflammation of the tonsils, pharynx, and 
larynx. In none of these were the Loeffler bacilli found to be present. 
These cases occurred in two hospitals for children in New York in which 
both scarlet fever and measles were at the time prevalent. During the past 
year we have examined the exudate from 46 fatal cases of suspected diph- 
theria occurring in these same institutions, and found the bacilli present in 
44 of them." 

If scarlet fever and measles (but not true diphtheria) were prevailing 
in an institution, it is evident the bacilli would be absent from the pseudo- 
membranes occasionally occurring in the throat as a complication of these 
diseases. 

The Mortality in True Diphtheria and in Pseudo-diphtheria. — All 
observers have found the mortality far higher in those cases in which the 
diphtheria bacilli were present than in those in which they were absent. In 
true diphtheria the mortality has been found to vary from 25 to 70 per 
cent., while in pseudo-diphtheria it varies from per cent, to 20 per cent. 

The death rate in cases of pseudo-diphtheria occurring in hospitals 
averages far higher than the death rate outside of such institutions. The 
reason for this is chiefly to be found in the fact that it is mainly the graver 
cases, especially those suffering from laryngeal obstruction, which are re- 
moved to the hospitals. 



CHAPTEE VII. 

RUBELLA (ROTHELN, GERMAN MEASLES, FALSE MEASLES). 

Eubella is an exanthematous eruption simulating measles. Corlett's 
description of rubella is so classic that I give it word for word. 1 

"Eubella is a mild form of infection which always follows a benignant- 
course and first appears as a general or constitutional disease, accompanied 
by a slight rise of temperature and slight feeling of illness. In this it 
conforms to the other affections of this class. 

"The local manifestations, while partaking of the character of those 
observed in both scarlet fever and measles, are distinct, and possess an 
individuality which, as a rule, may be recognized by the trained eye. 

"Etiology. — While we have no exact knowledge of the cause of the 
disease and in what respect the virus differs from that of other diseases to 
which it bears the closest resemblance, yet we do know that it is contagious, 
and always gives rise to a like disease : in short, conforms to the type. 

"It occurs but once in the individual, from which we infer that it is 
self -protective, while it affords no protection to or modification of measles 
or scarlatina; nor has it appeared that they offer any protection against 
rubella. It must be remembered, moreover, that even mild forms of the 
various exanthemata are self-protective. The fact that the patient has had 
at some previous time either scarlet fever or measles, or both of these 
affections in a well marked degree, often leads to its recognition. Some- 
times, even before its true nature has been definitely settled in the mind 
of the medical attendant, the disease disappears. 

"Like the other exanthemata, it always appears in the form of an 
epidemic, which seems to bear little or no relation to epidemics of other 
diseases, such as scarlet fever or measles." 

Bacteriology and Pathology. — Owing to the mild character of the dis- 
ease, the pathological changes have not been studied. There are certain 
changes seen in the skin, described by Thomas. Nothing definite, however, 
can be stated. Bacteria in the blood of children suffering with rubella have 
been described by several authors; these are by no means pathognomonic 
of this condition. 

"It sometimes occurs independently; again, two or more of the epi- 
demic exanthemata prevail at the same time. It must be admitted that ex- 



1 For a very minute description of this disease the reader is referred to Corlett's 
'Treatise on the Acute Exanthemata.'' Published by F. A. Davis Company. 

(622) 



RUBELLA. 623 

trancous conditions of weather and possibly of sanitation predispose in a 

like degree to all. Though epidemics of rubella seem to occur ai 
qnent intervals than do those of either scarlatina or measles, there can be no 
doubt that very many epidemics of rubella escap< gnition, and are re- 

garded as mild or aberrant forms of one or the other of the first named 
affections. While the author believes, with Atkinson, that unless more 
exact methods are adopted in the study of the exanthemata there is 
danger of endless confusion, and that the practice of relegating all mild or 
otherwise anomalous forms of measles or scarlatina to rubella is, as it was 
thirteen years ago, far too prevalent ; yet the remedy lies in giving to this 
important group of affections a more conspicuous position than it now holds 
in the curriculum of clinical instruction." 

The period of incubation is usually from fifteen to eighteen days. 

Symptoms and Diagnosis. — The symptoms may be so mild that they 
are frequently overlooked. The prodromal symptoms appear a few hours 
before the rash is seen. Some authors state that in the majority of cases 
they are wholly absent. I have frequently seen catarrhal symptoms such 
as coryza in addition to suffusion of the eyes, on the day previous to the 
eruption. 

Throat symptoms, such as congestion and swelling of the tonsils and 
fauces, are usually seen. Cough and hoarseness may also be present. The 
buccal mucous membrane does not have an enanthem. Forchheimer 1 
describes what he considers a characteristic enanthem in rubella which 
appears simultaneously with the exanthem and remains from 12 to li 
hours. Its favorite location is on the soft palate, sometimes extending to 
the hard palate. It consists of small discrete dark red but not dusky papules, 
which soon disappear, leaving no trace behind. The rest of the mouth 
may or may not be congested. 

Sometimes there is anorexia and occasionally nausea or vomiting. J. 
Lewis Smith describes convulsions seen in the disease. The temperature 
varies between 100° and 101° F., rarely higher. The tongue is not as 
thickly coated as in measles, although the papillae may be enlarged. These 
projecting papillae appear on the tip of the tongue. The characteristic 
strawberry tongue is absent. 

Sneezing may be present and coryza may be absent, or vice versa. 

Thierf elder 2 states that "swelling of the subauricular and superior jugu- 
lar lymphatic glands may he looked upon as a constant prodromal symptom." 
Atkinson 3 says "enlargement of the superficial lvmphatic glands of the neck 
may be the most striking symptom, and sometimes attracts attention several 
days before the beginning of the eruption." 



x "German Measles," Twentieth Century Practice of Medicine, New York, 1898. 
2 Thierf elder: Greifsw. Med. Beitr., B. ii, Ber., p. U, 1SG4. 
•Atkinson (loc. cit., p. 23). 



624 THE INFECTIOUS DISEASES. 

Corlett 1 says "his cases show adenopathy in 96 per cent., of which the 
maxillary and superficial or post-cervical were the most frequently in- 
volved ; next the occipital, posterior and anterior auricular ; and sometimes 
the superficial inguinal, axillary, and the epitrochlear. In the neck the 
inflammation may be sufficiently severe to interfere with free movement, and 
in two or three instances it has given rise to marked oedema of the sur- 
rounding parts." Suppuration of the glands is never observed. The 
lymphatic ganglia are also involved in the regions affected. The spleen is 
seldom involved. 

Pauline M., 6 rears old, was brought to my office in an apparently good con- 
dition. I was told that the child had a rash on her chest and back, and that the 
temperature was 100° F. in the rectum. There was sneezing, but no cough nor 
bronchial symptoms. There was an enlargement of the glands on both sides of the 
neck along the posterior border of the sterno -mastoid muscle. The buccal mucous 
membrane, pharynx, and tonsils were but slightly inflamed. The conjunctivae were 
of a deep pink color. The rash was scattered over the abdomen and chest and was 
crescentic in its arrangement, similar to that seen in measles. The highest tempera- 
ture reached was 101° F., in the evening, pulse was 100, and the respiration 24. The 
treatment consisted in giving a mild laxative and liquid diet. Strict isolation was 
insisted upon. The eruption remained about three days. The child recovered 
without any complication. 

The Eruption. — The rash is first seen on the face and scalp. It is 
described as "faint pinkish maculae, at first discrete, but sometimes becoming 
more or less confluent within a few hours." The eruption spreads down- 
ward to the neck and upper part of the abdomen until the upper and lower 
extremities are covered. The palms and soles are usually associated in this 
general eruption. The eruption reaches its full development after one or two 
days. It spreads slowly and fades on the face when it is about reaching its 
height on the lower extremities. Hardaway believes that this dissimilarity 
in the appearance of the eruption is a valuable means of distinguishing ru- 
bella from measles. "The individual lesions are sometimes perceptibly ele- 
vated and vary in size from a pin-head to a small bean." They are often 
slightly elongated or irregularly round in shape, with an ill-defined border, 
and disappear completely on pressure. Unlike measles, they show no 
tendency to form groups, clusters, or crescents, and in some cases manifest 
a feebler predilection to coalesce. Sometimes, however, when confluent they 
extend at the periphery, coalesce, and form extensive areas, when the re- 
semblance to scarlatina may lead to an error in diagnosis. 

"Usually the plaques thus formed are found only on certain parts, while 
on the remaining portions of the body the eruption presents the more usual 
appearance. The color is always lighter than that observed in scarlet 



1 Corlett, "A Treatise on the Acute Infectious Exanthemata," p. 356. 



KIT.KU.A. 



625 



fever, and in a strong light the slight elevations which correspond to the 
original lesions may be discerned. Further, the eruption is fairly uniform 
in color and may be described as of a faded rose, or pink tint, never, in my 
experience, presenting the fiery red of scarlatina nor the dusky, bluish red of 
measles." 

Subjective Symptoms. — These are usually so mild that children do not 
complain. I have seen cases of rubella in the Kaiser and Kaiserin Frederick 
Hospital, in Berlin, while making rounds with Professor Baginsky, which 
were of a very mild nature and in which hardly any subjective symptoms 
were complained of. 

The Fever. — A peculiarity of this condition is that the fever does not 
correspond with the eruption, in intensity. Von Nymann studied 119 cases 



DATE 


11 


1Z 


13 


74- 


45 


TEMP. 
FAHR. 


M 


£ 


M 


E 


M 


E 


M 


E 


M 


£" 


10/' :£ 


^ 


r***+ 


^^ 


^S 














i 














H 


*^S 


kn 





Fig. 197. — Temperature Chart. Case of Rubella. (Original.) 



of rubella. He found that 58 cases showed no rise in temperature. In 
the remaining 61 cases the temperature was as follows : — 

In 39 cases the highest record was 100.4° F. (38.0° C.) 

In 14 cases the highest record was 101.3° F. (38.5° C.) 

In 6 cases the highest record was 102.2° F. (39.0° C.) 

In 2 cases the highest record was 103.1° F. (39.5° C.) 

Fever never remains more than four days unless some complication ex- 
ists. The pulse and respiration do not show much change, but usually cor- 
respond with the temperature. Sometimes a slight albuminuria is present. 

Desquamation. — A general desquamation is absent. Just as the rash 
spreads from place to place and is regional in character, so also is the 
desquamation regional. There is therefore no distinct stage of desquama- 
tion that can be applied to the disease as a whole. 

Differential Diagnosis. — The following distinctive points are taken 
from Corlett: — 

"First. — That rubella is sometimes feebly contagious, while measles is 
always violently contagious. 



626 THE INFECTIOUS DISEASES. 

"Second. — The prodromal stage is always short and quite insignificant 
in rubella, while in measles it continues from three to four days. 

"Third. — In measles the prodromal stage is usually accompanied by 
marked constitutional symptoms, with catarrh of the upper air passages, 
lacryniation, photophobia, and a more or less characteristic eruption in the 
mouth, which appears from twelve to forty-eight hours before the cutaneous 
exanthem. In rubella no characteristic prodromata are observed, and only 
at the beginning of the eruptive stage is there usually a slight hyperaemia of 
the conjunctiva?, of the faucial mucous membrane, and rarely of the upper 
air passages. On the soft palate and uvula there is* sometimes a punctate or 
faint macular enanthem, which by some is considered distinctive. Even in 
mild cases of measles the disturbance of the mucous membranes is more 
severe than in severe cases of rubella, and there is always, so far as I have 
observed, a bluish or skim-milk tint to the mucous membrane of the mouth, 
which I have never found in rubella. In rubella, sore throat is present in 
nearly all cases, while in measles sore throat is uncommon. 

"Fourth. — The eruption in rubella appears most frequently on the first 
and second day, rarely later. It often disappears from parts first attacked 
before other regions become involved. It is of a pale red or pinkish color, 
very rarely assuming a dusky tint, and the individual spots are surrounded by 
a faint areola, thus obscuring the outline of the lesion. The spots are 
papulo-macular, for the most part round or slightly oval in shape, and 
present no tendency to form crescents or groupings. Sometimes by 
coalescing they unite to form extensive areas, which in all cases, either at 
the periphery or on more remote parts, are associated with the discrete, small 
macules which give character to the eruption. The rash rarely lasts longer 
than three days, and most frequently it disappears on the upper part of the 
body on the second; while in measles the eruption almost always appears 
on the morning of the fourth day, sometimes on the third, and rarely 
earlier. In measles the color is of a dark or purplish red, and the lesions 
are well defined, with normal skin intervening. They enlarge at the 
periphery and show a marked tendency to form groups and crescents. These 
are especially marked on the face, neck, and upper part of the trunk. In 
all cases the individual lesions are larger than in rubella ; so that the whole 
surface of the body may be involved at the same time, consequently, it 
remains longer than that of rubella, lasting from four to five days, or longer, 
when defervescence begins. 

"Fifth. — In rubella the superficial lymphatic glands of the neck are 
nearly always involved, being swollen and sometimes painful; while in 
measles marked or painful enlargement of the glands of the neck is 
decidedly uncommon. 

"Sixth. — In rubella the temperature may be only slightly above the 
normal at any time during the course of the disease, and it rarely exceeds 



RUBELLA. 627 

102° F. (38.8° C). Nor is the temperature curve in any way characteristic 
of the atl'ection. Further, it is usually of short duration and rarely contin- 
ues beyond the second or third day. Jn measles fever is always present and 
the temperature is sometimes high. There is an initial rise of temperature 
during the prodromal stage, which visually subsides, returning just previous 
to the appearance of the eruption, and attaining its maximum at the height 
of the efflorescence. The fever may continue until the seventh or eighth 
day. 

"Seventh. — Rubella is seldom accompanied by complications or fol- 
lowed by sequelae, while in measles complications are common and constitute 
the most serious feature of the disease." 

In studying the above we can readily see that measles is very frequently 
mistaken for rubella. Scarlet fever has a small punctate rash very uniform 
in character. The temperature, and the characteristic throat and tongue 
will usually differentiate this condition. 

S} r philis is frequently mistaken for rubella, but the absence of the 
characteristic initial lesion will aid in establishing the true diagnosis. Be- 
fore making a positive diagnosis we should see that our patient is not suffer- 
ing from a drug eruption. 

Complications. — These are rarely seen. The disease is so benign that it 
rarely leaves any after-effects. Recurring rashes have been described by 
various authors, hence, a relapse is possible. This second rash does not 
differ in character from the first. The contagious nature of this condition 
has been well established. Hatfield reports 1 that of 196 children in an 
asylum, 110 were affected. Corlett believes that it is as contagious as 
measles, but the contagium retains its vitality longer and hence resembles 
scarlatina. The infectious nature of this disease has been studied by Ed- 
wards, who found that 75 per cent, of cases in an epidemic in Philadelphia 
could be traced to infection from the bunks of ships. 

Course. — Rubella runs a mild course. Cases seen by me during an 
epidemic in the winter of 1903-1904 remained ill about three to four days, 
rarely five days. Some authors state that children with rubella are ill one 
and two weeks. 

Prognosis. — This is always good.' With good sanitary surroundings, 
aided by careful diet, recovery always takes place. 

Treatment. — A child with rubella should be put to bed and kept con- 
fined until all evidence of eruption has disappeared. A liquid diet should 
be prescribed. The gastro-intestinal tract must be watched ; the bowels and 
kidneys assisted if necessary. 



1 Chicago Medical Examiner, August, 1881. 



CHAPTEE VIII. 

MEASLES (MORBILLI, RUBEOLA). 

Measles is an acute eruptive disease associated with fever. It is 
caused by the invasion of a specific micro-organism the character of which 
has not yet been definitely determined. 

Etiology. — Measles is a contagious and to a less extent an infectious 
disease. It is usually communicated direct from person to person. Inter- 
mediate contagion is comparatively rare. Contagion is possible three or four 
days before the rash appears on the skin, and continues until desquamation 
has ceased. Children differ as to their susceptibility, some contracting the 
disease by very short exposure, while others require a longer and more inti- 
mate contact. 

The disease can be more readily conveyed in poorly ventilated or 
crowded apartments, schools, and kindergartens, where many children are 
intimately associated. 

The disease is characterized by coryza, and a congestive condition of the 
conjunctivas, with more or less catarrh of the respiratory tract, accompanied 
by an exanthem. This disease is always accompanied by high fever. One 
attack usually confers immunity. The mortality is usually low in robust 
children. It is as high as 30 to 40 per cent, in rickety and bottle-fed 
children. The danger is not so much from the measles as it is from the 
complications, notably broncho-pneumonia and laryngeal croup. 

Period of Incubation. — The period of incubation ranges between nine 
and fourteen days, the average being eleven days. Some authors 1 give 
eighteen to twenty-one days as the period of incubation when measles occurs 
a second time. 

Bacteriology. — In the blood of fatal cases, the staphylococcus pyogenes 
albus and the streptococcus pyogenes are found. Claisse 2 describes an acute 
septicaemia found in measles in very young children. In these cases the 
streptococcus was invariably found. 

Pathology. — In a study of the early mucous lesions in the mouth 
Slawyk found that the epithelial cells were thickened and in some in- 
stances had undergone fatty degeneration. No specific micro-organism has 
been found in the lesions. Frequently there is a tendency to the formation 



a Graham: Article on "Measles;" Morrow's "System of Dermatology," 1894, 
vol. iii. 

2 Revue de Med., May 10, 1893. 

(628) 



MEASLES. 629 

Tabu Na 96 Dt Ukafiam Meade* in Children Under IS Tears— Old OttwafNew York. 







Total 



Year. 


1 


3 
Years. 


4 

Years. 


-M in-ir, 
5 Yrs. J • m, Years. 


1890 


Males 

Females 


381 
313 


121 

99 


139 59 

141 51 


35 


11 
13 


365 
327 


16 
15 


1 


1891 


Males 311 
Females j 346 


82 
94 


lit; 4-2 

138 59 


•> 
26 


25 

17 


293 
334 


18 
12 




1898 


Males 
Females 


44< 
410 


151 

111 


166 61 
150 66 


33 

32 


19 
24 


430 
383 


17 
27 


1 



1S93 



1894 



Male? 
Females 



198 57 

191 54 



67 



*, 



14 
37 17 



189 

180 



Males 
Females 



297 

(KM 



96 108 

94 



a i 

42 



25 
31 



8 : 277 
12 267 



10 



19 
15 



159^ 



1895 


Males 
Females 


371 
417 


84 
105 


167 
157 


6-2 
72 


31 
45 


12 
15 


356 ' 
397 


13 

19 


2 

1 


1596 


Males 
Females 


352 
353 


99 


119 
133 


69 

77 


30 
31 


19 


336 
337 


15 
15 


1 
1 


1-97 


Males 
Females 


191 
196 


53 
55 


-0 
79 


30 


17 
17 


5 
5 


1-5 
184 


6 

10 


o 



Males 
Females 



252 
190 



76 112 39 
48 88 28 



11 
13 



246 
185 



1-99 


Males 
Females 


202 
176 


60 
35 


-1 
90 


27 

h 


12 
10 


6 
9 


156 

171 


15 
5 


1 


1900 


Males 
Females 


237 
227 


60 
56 


95 

101 


40 
26 


16 

17 


11 
12 


222 

212 


12 

14 


3 

1 


1901 


Males 
Females 


149 

115 


37 
24 


53 

48 


26 
25 


12 
12 


10 
3 


135 
112 


11 

6 





of ulcers, which extends to the deeper parts. t'nna called attention to the 
thrombosis of superficial vessels of the skin in a severe type of measles re- 
sembling smallpox. When gangrene existed streptococci were always pres- 
ent. Corneil and Babes report a special form of pneumonia beginning as an 
interstitial pneumonia and later giving rise to a fibrinous effusion into the 
alveoli. It involves the lymphatic system, the interlobular and interalveolar 
tissue. The toxic effect of the measles virus resembles pathological changes 
noted in diphtheria. They can be found in the central nervous system. Xo 



630 THE INFECTIOUS DISEASES. 

doubt the toxin generated by a specific organism similar to that of the 
Loeffler bacillus found in diphtheria causes the degenerative changes. 

Symptoms. — Prodromal Stage or Period of Invasion: The first symp- 
toms are those of an ordinary coryza, sneezing, dry cough, and watering 
of the eyes (lacrymation), with photophobia. Moderate fever, temperature 
from 101° to 102° F., rarely higher during the first day. There is some- 
times vomiting. 

This condition lasts about three days and is followed, by the character- 
istic eruption. This eruption is first seen on the face or neck on the morning 
of the fourth day. Very young infants show extreme irritability and rest- 
lessness. The tongue is covered with a white fur. The papillae are red and 
swollen. They are not as conspicuous as in scarlet fever. There is intense 
dryness, and thirst, with marked anorexia, and usually constipation. 

The temperature shows great variability. Wunderlich, Thomas and 
von Jurgensen, who have studied the temperature exhaustively, state that it 
cannot be considered characteristic, owing to its frequent variations. The 
temperature after having reached 102° F. or even 104° F. will on the second 
day of the disease drop to nearly normal. There is usually a morning re- 
mission to the temperature. The temperature in a characteristic case is 
sometimes deceptive, so that after three or four days of illness, there may 
be a sudden activity of all symptoms with a rise of temperature. The tem- 
perature frequently reaches 105° F. 

Early Symptoms of Measles.— -The absence of the thick epidermic cover- 
ing which masks the first pathological manifestations in the skin (exanthem) 
is more readily seen on the delicate mucous surfaces (enanthem). 

The enanthem in measles has long been known. It has been studied 
by Willan, in 1806; by Heim, in 1812; in Dunglison's "Cyclopaedia of 
Practical Medicine," in 1854; by Trousseau, in 1866. Memeyer^s "Prac- 
tice of Medicine," 1876, vol. ii, p. 528, mentions Eehn, who studied an erup- 
tion in the cheek, gums, lips, and fauces. Eilliet and Barthez, 1854, and 
Monti, in 1873, devote considerable attention to the prodromal enanthem of 
measles. 

Flindt, of Denmark, describes it at length in the "Sundheds-collegium," 
as follows : — 

"First day of the fever : A slight, diffuse erythema of the throat. 

"Second day of the fever: A fairly dark redness without marked 
oedema of posterior pharyngo-palatine arch and tonsils, which on the 
anterior palatine arch (arcus glosso-palatinus) and velum palati is some- 
what less deep in color and of an irregularly diffused or mottled appearance. 
On the evening of the second day of the fever the mucous surfaces of the 
tonsils, and the posterior palatine arch, have undergone but little or no 
change, appearing as a uniformly red erythema, with slight oedema. On 
the anterior surface of the soft palate, and the posterior part of the hard 



MEASLES, 631 

palate, as well as occasionally on the remaining normal mucous surfaces, a 
distinct enanthema appears. The lesions are round or irregular in shape, of 
a bright red color, having an ill defined margin, with little or no elevation 
at this time above the surrounding surface. They range from a pin-head 
to a lentil in size, and occur singly, or are scattered irregularly over the 
surface. In places there is a tendency for the lesions to cluster in groups 
and to become blended. 

''They acquire a peculiar appearance on account of numerous small, 
white glistening points (simulating minute vesicles), which occupy the 
middle of the small red macules. These manifestations in the macules are 
irregularly grouped. One can see and feel the minute vesicles elevated above 
the surrounding areas. The palpebral conjunctiva is hyperaemic in its 
entire extent. Besides the reticular and macular reddening of the con- 
junctiva, which is due to the disposition of the conjunctival vessels, there are 
also small, glistening, miliary elevations similar to the elevations in the 
palate. 

"Third day of the fever: The mucous surfaces of the buccal cavity, 
which up to this time have been only slightly hyperaemic, are now found to 
be invaded by the lesions previously described. These latter are strongly 
marked over the entire anterior surface of the velum palati, the glosso- 
palatine arch, and usually also over the contiguous two-thirds of the hard 
palate. The red spots are sometimes very numerous, at other times isolated, 
and again, by blending, they form irregular figures of a stronger red than 
previously seen. Here and there a faint appearance of the previously 
described vesicle-like formations is seen projecting above the surrounding 
surface. On the other hand they may also be found on the apparently 
normal mucous membrane. Similarly grouped spots with whitish vesicles 
now also appear on the inner surface of the cheeks, especially on the part 
opposite the juxtaposition of the upper and lower molar teeth. 

"As a rule, the gums and the inner surface of the lips retain their nor- 
mal color, or at most are only slightly hypersemic. It is, indeed, seldom that 
the eruption appears on these parts. The tonsils and both pharyngo- 
palatine arches still remain red. 

"The palpebral conjunctiva retains its deep red color, but no spots are 
visible, excepting the minute vesicles previously described. At this time the 
eruption breaks forth on the skin. On the evening of the third day there 
is little or no change perceptible. 

"Fourth day of the fever : On the palate and inner surface of the 
cheeks the spots stand out prominently, while in many places there is a 
tendency to merge by enlargement of the individual lesions, and on the 
surfaces last invaded they are more copious than ever. The conjunctival 
exanthem is now disappearing. On the evening of this day there is no 
change noted. 



632 THE INFECTIOUS DISEASES. 

"Fifth day of the fever: The exanthem in the buccal cavity is more 
marked than heretofore. Frequently at this time there appear faint-reddish 
spots on the mucous surfaces of the lips, even extending to the exposed 
cutaneous margin. On the gums they are seldom present and never distinct. 
The hyperemia of the posterior fauces remains unchanged. The skin 
exanthem begins to fade, and the temperature falls. 

"Sixth day of the fever : The exanthem of the mucous surfaces is no 
longer visible, except a slight diffuse redness of the palate and the inner 
surface of the cheeks. Fever ends." 

This characteristic enanthem is seldom absent. Slawyk 1 found it 
present in 90 per cent, of all cases examined. 

Koplik described these symptoms 2 and to him belongs the credit of 
having popularized the enanthem. It is generally known as Koplik's sign. 
The spots are best seen on the inside of the cheeks opposite the molar 
teeth, although I have seen them very clearly defined on the mucous mem- 
brane of the upper lip corresponding to the incisors. 

The patient must be examined in a strong sunlight or with a good 
electric light. A yellow gaslight, for instance, is very unsatisfactory. 

Differential Value of this Sign. — This enanthem is of great value 
in differentiating measles from other exanthemata, notably, however, from 
antitoxin rashes, drug eruptions, and eruptions associated with toxaemia 
from gastric fevers. 

Period of Effloresence (Eruptive Stage). — The eruption usually appears 
on the fourth day of the disease. Sometimes it appears as early as the 
third and sometimes as late as the fifth day. The first spots appear on the 
forehead or the temples, behind the ears, and on the sides of the neck. 
Later, spots appear about the eyes, mouth, and chin. When the rash is at 
its height then a crescentic character, first described by Willan, will be 
noticed. The constitutional disturbances increase in severity. The cough 
is more pronounced and there is a decided interference with the respiration. 
Nose bleed is quite frequent. Constipation is usually followed by very loose 
bowels. 

The Rash. — The rash is of a dark red, sometimes a purplish color, of a 
round, oval or irregular shape. The skin between the rash remains 
intact, although the face has a puffy oedematous appearance. The eruption 
extends over the trunk and extremities, including the palms and soles, the 
arms and legs, the forearms and legs being the last to become affected. 

When the rash reaches its height the constitutional symptoms subside. 
It is not infrequent to see a normal temperature two days after the rash has 
completely covered the body. In some instances there is a crisis, although 



1 Slawyk: Dent. med. Woch., April 28, 1898. 

8 Archives of Pediatrics, December, 1896; Medical Record, 1898. 



MEASLES. 633 

the usual rule is for the temperature to fall gradually by lysis. A sub- 
normal temperature frequently follows and accompanies the period of con- 
valescence and until the patient is normal. 

The catarrhal symptoms continue to increase in severity with the devel- 
opment of the rash. 

There are moist rales heard on auscultation. The sputum as well as the 
nasal discharge become sero-purulent. A bronchitis or a pneumonia should 
be suspected, if the respiration is exaggerated. The pulse-respiration ratio 
will be found of great value in diagnosing latent pneumonia. The urine 
will show the excess of urates and sometimes transitory albuminuria or 
hyaline easts may be found. The diazo reaction is sometimes noted, but it 
does not teach us anything of value in either the diagnosis or prognosis. 
This stage of the disease rarely lasts more than from four to six days. 

Stage of Desquamation or Convalescent Period. — The eruption on the 
skin of the face, neck, and upper part of the chest fades and there is a slight 
branny desquamation. This is less marked than in scarlet fever, and is so 
fine on the trunk and extremities that it may be unobserved. It is best seen 
on the sides of the nose, temples and chin. Large, flaky scales are rarely 
met with in measles. After the eruption disappears, a certain amount of 
pigment remains for a week or two where the rash existed. 

Atypical or Anomalous Conditions. — Certain symptoms of normal 
measles vary in different epidemics, although the majority of cases present 
distinct clinical features. Predisposing factors, such as rickets and scurvy, 
possibly tuberculosis, w T ill frequently alter the type of the disease or 
modify the symptoms. Edgar 1 reports an epidemic of 423 cases in which 
123 adhered to the regular type. 

Mild Forms. — Measles may be present without catarrhal symptoms. In 
such cases fever may be slight or absent. In other cases the catarrhal 
symptoms are severe while the cutaneous exanthem is almost wholly absent 
(morbilli sine morbillis). Such cases might readily escape notice unless 
they partake of a series during an epidemic, in w T hich both the mild and 
the severe type are found. 

Relapsing Form or Second Attack. — A relapse is said to occur in rare 
instances, after the exanthem has disappeared. When the second rash 
appears there is a return of fever and also the other constitutional symp- 
toms. Eecurring measles is often a very serious matter, owing to the 
already weakened state, resulting from the first invasion. 

Corlett doubts the so-called relapses and believes that they are due to 
a direct reintoxication by the specific virus. 

Severe or Malignant Forms. — Malignant measles is that form in which 
there is a very high fever, rapid pulse, labored breathing, and great prostra- 



1 Can. Med. Record, December, 1892. 



634 



THE INFECTIOUS DISEASES. 



tion. The fatal issue most frequently occurs on the second day of the 
exanthem. We frequently meet with a typhoidal or a toxic form in which 
the symptoms are of a most malignant character. The mouth becomes 
parched and the tongue brown and dry, resembling a typical typhoidal con- 
dition. 

The bowels are loose and the quantity of urine diminished. Convul- 
sions resulting from the general toxaemia are very common. It is usually 
fatal and rarely ends in recovery. Where there is severe respiratory dis- 
turbance, with difficult breathing, it is called the suffocative form. In this 
form we have principally cough and expectoration with severe dyspnoea. 

The patient is cyanotic. Mucous rales are heard early in the disease, 
and it not infrequently ends in a broncho-pneumonia. 

Hemorrhagic forms, known as the black measles, are frequently de- 
scribed. The mild form of hamiorrhagic measles has been described by 
various authors. Edgar reports 200 cases out of 423, or 47 per cent, of the 
hemorrhagic form. Holt found it in 5 per cent, of his cases. The cutane- 
ous exanthem assumes a dark bluish or purplish tint, which gradually deep- 



Table No. 87. — Showing 503 Cases of Measles and Complications, Treated in the Riverside 
Hospital, New York City, During the Months of January to July, Inclusive. 





No. of Cases. 


Uncompli- 
cated Measles. 


Measles 

and 

Diphtheria. 


Measles 

and 

Pneumonia. 


Measles, Sear- 
let Fever and 
Diphtheria. 


Measles and 
Scarlet Fever. 


1904 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


Cases 


Deaths 


Jan. 


34 


4 


31 


1 


2 


2 


1 


1 










Feb. 


70 


8 


62 


1 


7 


6 


1 


1 










Mar. 


133 


14 


111 


2 


9 


6 


4 


4 


2 


1 


7 


1 


Apr. 


103 


15 


84 





8 


8 


10 


7 


1 









May 


106 


16 


77 


2 


13 


4 


13 


8 


1 


1 


2 


1 


June 


37 


8 


23 





7 


3 


7 


5 










July 


20 


5 


12 





3 


1 


5 


4 










Total 
Cases 


503 




400 




49 


30 


41 




4 




9 




Total 
Deaths 




70 




6 






30 




2 




2 



MKASLKS. 



635 



ens as the process continues, to a bluish-black color. Frequently the whole 
body shows a tendency to bleed. Thus the mucous surfaces are implicated, 
giving rise to epistaxis, bleeding from the gums, dysentery stools and 
haemorrhages from the genito-urinary tract. Where a tendency to hajmor- 
rhage exists, as in hemophilic subjects (bleeders), they are especially predis- 
posed to the hemorrhagic form. 




Fig. 198. — A Case of Malignant Measles, complicated by Diphtheria and 
ending with Empyema. Male child, 3 years old. Septic from beginning. 
Fatal termination. Seen in my service at Riverside Hospital, New York 
City. (Original.) 



Complications. — Pulmonary: There seems to be a predisposition to 
pulmonary disease, commencing with a bronchial catarrh, especially in those 
children with feeble resisting power. The inflammatory condition extends 
into the smaller ramifications of the bronchial tubes, causing capillary 
bronchitis. When this occurs it should be viewed with alarm. The child 
shows dyspnoea and adynamic symptoms, owing to difficult oxygenation. 



636 



THE INFECTIOUS DISEASES. 



The Larynx. — One of the most frequent and fatal complications met 
with in children is laryngitis. This may be : — 

(a) Spasmodic. 

(o) Phlegmonous. 

(c) Membranous. 

The last named complication is the one most frequently met with, espe- 
cially in institutions. It is most common during the eruptive stage as early 
as the third or fourth day. The symptoms are the same as those met with 
in laryngeal diphtheria accompanied by stenosis of the larynx. 

The Klebs-Loeffler bacillus is sometimes found on bacteriological ex- 
amination of the pseudo-membrane. It can be found in 6 to 10 per cent, of 
all cases of membranous laryngitis. 



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Fig. 199. — Temperature Chart from a Case of Measles Complicated by 
Broncho-pneumonia. Seen during my service at the Riverside Hospital, Xew 
York City. (Original.) 

Broncho-pneumonia. — This is the most frequent and the most fatal 
complication of measles. Houl 1 found it in one-fifth of all of his cases. In 
the Nursery and Child's Hospital of Xew York. Holt observed it in 40 per 
cent, of all cases. This infection can invariably be traced to the presence of 
various organisms of which the pneumococcal of Friedlander, and the 
micrococcus of Frankel play a conspicuous role. 

There is marked retraction of the chest in addition to the usual signs 
of pneumonia. The physical examination shows widely disseminated sub- 
crepitant rales which soon give way to definite resonance, bronchial breath- 
ing, and fine crepitations. In young children its onset is acute, with rapid 
pulmonary congestion, and it usually terminates fatally within two or three 



Wien. klin. Kund., 1897, vol. xi, p. 833. 



iMKASLKS. 



637 



days. When the condition extends over a more subacute course, it may lead 
to caseous pneumonia or pulmonary tuberculosis. 

Case I. Kate A., aged twenty-one months. Child was admitted to the Riverside 
Hospital August 25, 1904, in fairly good condition, with temperature 104° F., pulse 
130, respiration 36. Sick since August 22d. Child had a moderately severe cough on 
admission. On August 26th cough increased in severity, breathing short, rapid and 
labored. 

Physical examination showed only a few coarse rales at upper part of chest 
posteriorly, with slight dullness, but no bronchial breathing. 



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Fig. 200. — Temperature Chart from a Case of Measles Complicated by 
Broncho-pneumonia. Seen during my service at the Biverside Hospital, 
New York City. (Original.) 1 






Well-marked dullness over the right base posteriorly, with bronchial voice and 
breathing. Left base behind gave slight dullness with many coarse rales. No bron- 
chial breathing. 

On August 28th, pleuritic friction sounds over right base posteriorly. 

On August 31st, percussion gave marked dullness, almost flatness over this 
area, extending slightly above the inferior angle of right scapula. Over this area, 
marked bronchial voice and breathing. 



J I am indebted to Drs. Alfred Helgeson, Bruno Horwicz, and Wm. Ogden Lord for 
clinical histories, charts, and statistics. 






63S . THE INFECTIOUS DISEASES. 

On September 1st, bloody serum obtained upon aspiration. 

On September 3d, serum obtained by aspiration, bloody with, slight turbidity. 
General condition continued the same up to September 9th. On this day a drop in 
the temperature from 102° to 97.6° F. occurred. Child appeared brighter, slept well 
and has a good appetite. 

During the last two days, fluctuations in temperature have occurred, ranging 
from 98° to 101° F. (evening rise). 

This fluctuation of temperature continued up to September 14th. On this date 
there was an evening rise to 99° F. only, and since then, the highest rise has been 
99 3 / 5 ° F. The pulse has improved much in quality. Respirations have gradually di- 
minished in frequency. The child was aspirated on the 13th, but no pus or serum 
was obtained. Dullness was diminished over right base posteriorly and bronchial 
breathing was present only over a small area at base of right lung. Child at present 
sits up, has good appetite, and sleeps well. 

Case II. L. Z., age eight months. Admitted to the Riverside Hospital on August 
29th, having been ill since the 21st. Upon admission showed characteristic symptoms 
of broncho-pneumonia with temperature 101.4° F., pulse, 150; respiration, 56. Upon 
examination, dullness was present over right base behind, with bronchial voice and 
breathing. Many coarse rales were heard over both lungs behind as well as in front. 
There was a pleuritic friction sound over the consolidated area. No signs of effusion. 
Child improved rapidly, and upon September 3d, the bronchial breathing had disap- 
peared and only signs were coarse rales over both bases behind. Recovery. 

Otitis Complicating Measles. 1 — A very frequent sequela is acute otitis. 
If, after several days of apparent convalescence the child is irritable, restless 
at night and feverish, and cries continuously, a careful examination of the 
ears should be made. As a rule our attention is first directed to this con- 
dition after the cavity of the middle ear is filled with the discharge, and 
there is a spontaneous discharge of pus. 

Siegfried Weiss 2 calls attention to the method of prophylaxis in this 
condition. He believes that with good care we can prevent and abort this 
complication. Tobeitz believes that in measles we are dealing with a pri- 
mary enanthematous disease of the middle ear. 

In a post-mortem study of 95 cases, pathological changes affecting the 
ear showed the destructive tendency due to the disease itself. 

Tobeitz found that 86 per cent, of fatal cases of measles showed ear com- 
plications. Bezold in a study of 18 fatal cases of measles noted ear disease 
in 17, or about 95 per cent. Weiss studied 112 cases in which there were 
ear complications, and after careful prophylactic treatment he had only 6.6 
per cent, of ear complications. Weiss's prophylactic method consists in ap- 
plying a 1 per cent, yellow precipitate ointment on a sterile swab to the 
nostrils. By this method he removes the dried and fluid secretions from the 
nose mechanically. Another method of Weiss' consists in allowing 1 or 2 
drops of 1 / 2 per cent, nitrate of silver solution to drop into the nostril. In 



1 Read chapter on "Otitis." 

2 Wiener Medicinische Woehenschrift, No. 52, 1900. 



MEASLES. 



639 



this manner he believi an destroy the specific infectious material. 

Hayek has long advocated this method in the treatment of chronic rhinitis 
in children. In using the salve or the silver nitrate solution Weiss found 
that if it was applied three or four times a day, the percentage of compli- 
eations was greatly reduced. 



Table No. 83. — Measles Stat sties Showing 
Ear Coniplications. Riverside Hospital. 



1<HU Number of 


Measles and 
Otitis. 


January 31 


6 


February 74 


n 1 


March 127 


10 


April 101 


14 


Total 333 


41 , 



Empyema. — Empyema is occasionally met with during the course of 
measles. As there seems to be a decided tendency to suppurative formations, 
it is well to inspect the thorax and be sure that we can exclude empyema. 
This should be borne in mind if cough exists associated with fever. I have 
seen empyema complicating measles in about 2 per cent, of my cases. When 
the exploratory puncture shows pus the treatment is the same as that given in 
the chapter on "Empyema." 

The Eyes. — Severe infianimatory and destructive changes are met with 
in measles. Abscesses of the conjunctiva or keratitis, resulting in ulceration 
of the cornea, are sometimes seen. In other cases it may extend to the 
antrum or, if the mastoid cells are involved, it can result in meningitis, 
cerebral abscess, or pyaemia. In very young children the petromastoid 
suture, which at this time is still patent, allows free access of pus into the 
cranial cavity from the middle ear. Xot infrequently this condition leads 
to actual deafness. 

Immunity. — One attack of measles usually confers immunity for life. 
Second attacks are, however, possible, and third attacks have also been re- 
ported as instances of rare conditions. 

Measles is rarely seen in infants under 1 year. Mayr observed that of 
10 nurslings exposed to measles, only one contracted the disease. I have 
rarely met with infectious diseases in healthy breast-fed infants. There 
seems to be some antitoxic property conveyed to the nursing infant through 
the serum contained in the breast- mill' of its mother. 



640 THE INFECTIOUS DISEASES. 

At the Biverside Hospital I have seen nursing infants, in the measles 
wards, that had been exposed and did not contract the disease. 

Immunity can be conveyed by a mother who has had measles, through 
her milk, but how long this immunity lasts remains still to be investigated. 

Diagnosis. — An ordinary cold with coryza, as met with in influenza, is 
sometimes confusing. Mistakes will occur unless we are careful to note the 
enanthem which is absent in influenza. The rise of temperature is less 
marked in influenza than in measles. 

The diazo reaction is sometimes observed in cases of measles. By its 
presence we cannot, however, diagnose measles. 

Drug Eruptions. — Some eruptions resembling measles are caused by 
quinine and antipyrin. The internal use of chloral is sometimes followed 
by an eruption. Cubebs and copaiba give an eruption simulating measles. 1 

Bites of insects, especially bedbugs, fleas, and mosquitoes, sometimes 
produce an eruption which resembles measles. As there is no febrile dis- 
turbance or any enanthem the differential diagnosis is easily made. The 
injection of antitoxin and antistreptococcic serum sometimes produces an 
eruption which is morbilliform in character. 

Course. — As a rule three weeks should elapse before a case of measles 
is permitted to return to healthy children. The quarantine should be ex- 
tended over this length of time. This applies to institutions as well as to 
private families. Isolation should be continued if a case suffers from any 
complication associated with the primary measles. In other words, measles 
otitis, measles vaginitis, or any other complication, requires isolation. 

Prognosis. — When reasonable care is taken, then this is one of the least 
fatal of infectious diseases. The vital point consists in guarding the patient 
against unnecessary exposures and attending to all functional disturbances. 
With proper attention to the diet and symptomatic treatment when neces- 
sary, there should be little or no trouble experienced. If the fever declines 
after the full development of the exanthem, the prognosis is good. 

If croup and diphtheria complicate measles, then the prognosis is al- 
ways grave. Broncho-pneumonia is usually fatal in one-third to one-half 
of all cases. Sometimes a broncho-pneumonia will be followed by tuber- 
culosis. Diarrhoea with or without bloody stools should always be looked 
upon as a serious complication. 

Treatment. — In the treatment of measles certain rules should in- 
variably be followed: — 

(a) Hygienic. 

(b) Dietetic. 

(c) Medicinal. 

Hygienic Treatment. — The temperature of the room should always be 



P. A. Morrow: "Drug Eruptions/' New York, 1887. 



MEASLES. G41 

uniform, no less than 68° F. and never more than 74° F. Modern clinicians 
assert that the former method in vogue, of bundling up the body and keeping 
the air of the room very hot, produces a certain amount of susceptibility to 
respiratory diseases. In this manner we invite complications rather than 
prevent them. The body of the child may be sponged with tepid or warm 
water, and fresh linen can be given every day. 

Overheated rooms cause more trouble during treatment of respiratory 
affections than any other factor. 

Light of the Room. — Careful observers have noted that the light in 
the room has absolutely nothing to do with the eyes. Owing to the in- 
flammatory state of the eyes, there is a normal photophobic condition. No 
one would think of putting a child in the beginning of measles in a 
glaring sunlight, but rather with its back to the light. At the measles pa- 
vilion in Berlin, under the supervision of Professor Baginsky, the hygienic 
conditions are perfect. Plenty of fresh air is admitted and also light. I 
have frequently had the pleasure of making rounds in the wards of this 
pavilion w T ith Professor Baginsky, and noted the above-named conditions. 
We do not darken the windows in the measles wards at the Eiverside Hos- 
pital of New York City, and the hygienic conditions regarding fresh air and 
fresh linen have been excellent during my term of service there. 

Dietetic Treatment. — We must not forget that in all febrile conditions 
the digestive function is impaired. The diet must be so regulated that there 
is proper assimilation. If subnormal conditions prevail, we must order a 
smaller quantity of food and allow a longer interval between feedings. 

A baby receiving pure milk should receive one-half milk and one-half 
oatmeal w T ater, and if it has been fed every three hours when in good health, 
then it is wise to try to feed every four or five hours during the febrile stage 
of measles. An important point to remember is that liquids are an im- 
portant part of the treatment. Soups, acidulated w r aters, and carbonated 
waters are grateful and indicated. Orangeade and lemonade are grateful, 
especially to relieve thirst. If the child is older and has been fed on solid 
food when in health, then all solids should be discontinued and liquid food 
substituted. Water should be given in large quantities. 

Medicinal Treatment. — If the eruption is tardy in appearing then a 
mustard foot-bath, using a tablespoonful of mustard in a foot-tub of warm 
water, 100° F., and adding warm water gradually until the temperature is 
about 105° F., will frequently hasten the appearance of the rash. This is 
as hot as the child can stand it for a few minutes. If there is a general 
depression of the vital powers, then give spir. mindererus, a teaspoonful 
every hour, until perspiration is active. This will also frequently hasten 
the appearance of the rash. One of my favorite drugs is tincture of aconite, 
in 1-drop doses, if the fever is very high. 



642 THE INFECTIOUS DISEASES. 

Pneumonia requires the same care and treatment as if it were not a 
complication or a sequela to this disease. (See chapter on "Pneumonia/') 

Diphtheria calls for the same treatment as if it was not associated with 
measles. 

Immunity from Diphtheria. — An injection of 300 to 500 antitoxin 
units will confer immunity from diphtheria in a case of measles. 

The urine must be frequently examined for a possible nephritis and 
treated accordingly. 

Convulsions frequently usher in the disease and should be very care- 
fully attended by rest, sinapisms, enemata of chloral, and possibly a few 
leeches to the neck. 

Epistaxis is usually an early but passing symptom, but if persistent, 
it should be treated on general principles and the cause looked into. The 
congestion during an attack of measles has frequently excited an otherwise 
quiet polypus to activity and caused alarming haemorrhages. 

For the relief of the cough I usually give : — 

Ifc Ammon. bromid 9 ij 3.00 

Syr. liquorit 3j or 25.00 

Decoct, althae ad §ij 50.00 

M. Tea spoonful every hour, for a child 1 year old, until relieved. 

For a child 2 years old: — 

IJ Codeine 2 grains 

Sacch. alb 1 x / 2 drachms 

M. Divide in chart Xo. X. Sig\: One powder every two hours until cough i9 
relieved. 

Summary of Treatment. — Give the child excellent hygiene — fresh air — 
protect the body with clean linen. Guard against draughts. Isolate the 
patient. 

Do not give solid food; liquid diet only, soups, broths, milk, butter- 
milk if tolerated, etc. 

Do not give useless drugs. Treat symptoms, such as hyperpyrexia, 
constipation, suppression of urine, and assist the emunctories. The greatest 
part of the treatment is the management of convalescence — codliver-oil, iron, 
Fellows' compound syrup of hypophosphites, malt preparations, cereals, 
butter, eggs, and cream ; meat sparingly ; all green vegetables ; oranges and 
lemons. 

Health can be restored by cautious management during the stage of 
convalescence. When cough remains and symptoms point to the beginning 
of tuberculosis, we must not lose sight of the fact that more can be accom- 
plished by climatic treatment — out of doors, in the country — than by in- 
door treatment. Complete change of air, to a more even climate like 
Denver, Colo., New Mexico, or Florida, will frequently restore the lungs to 
their normal condition. 



CHAPTEB 1\. 
SCARLET FEVER (SCARLATINA 

Scablet fever is an acute infectious, specific and contagious disease. 
The infection twists from the earliest symptoms and continues long after 
convalescence has been established. If a child has been exposed to scarlet 
fever, it should not be considered out of danger until eight or ten days have 
S£ :. and then only if there is no fever or throat manifestations visible. 
This disease is usually ushered in by vomiting and sore throat, accompanied 
by fever. If the child is old enough it will complain of headaches. 

The pulse-rate will be accelerated, and there is usually on the second day 
a distinct eruption visible. This disease presents several types : the mildest 
form, known as Scarlatina Simplex or the benign form, and the most ma- 
lignant type, Scarlatina Maligna, called by the French "Foudroyante.*'' 

There are a great many varieties between the two types just men- 
tioned, so that any sharp differentiation is quite impossible. 

Clinically, we note three distinct types : — 

1. The moderate or mild. 

2. The severe. 

3. The malignant or cerebral. 

I prefer the classification given by Corlett 1 : — 

(a) Simple. 

(b) Septic. 

(c) Toxic. 

Etiology. — Scarlet Fever and Milk: Hall 2 in a very interesting article, 
found, after an extensive review of the literature, that, "•'while scarlet fever 
occurs in epidemic form in those countries where cows'* milk forms a 
staple article of food, especially among children, it does not occur in coun- 
tries where cows' milk is not used as a food, or where children are raised 
on mother's milk only." This is true of Japan, where cows' milk is not 
used and domestic animals are scarce, and it is true in India, also, where, 
though cows' milk is used, the children are nursed by their mothers until 
they are 3 or 4 or even 6 years of age. 

While this immunity from scarlet fever, together with the absence 
of cows* milk as an article of food, may be simply a coincidence otherwi-e 



1 In hi? excellent treati-e on the "Acute Infection* Exanthemata." 
2 H. 0. Hall: New York Medical Record. November 11. 1899. p. 698 

643 



644 



THE INFECTIOUS DISEASES. 



explainable, does it not suggest the possibility of infection through the 
gastro-intestinal tract as perhaps the chief source? 

Climate. — Epidemics are more common in America in the fall and 
winter than in the summer months, although I have seen malignant cases 
both in hospital and private practice just as bad in midsummer as in mid- 
winter. We know by clinical experience that the poison of scarlet fever is 
less volatile than that of measles, and is not transmitted any great distance 
through the atmosphere (Hall). 

Table No. 89. — Deaths from Scarlet Fever, in Children Under 15 years— Old City 

of New York. 







Total. 



Year. 


l 
Year. 


2 
Years. 


3 

Years. 


4 
Years. 


Under 
5Yrs. 


5-10 

Years. 


10-15 
Years. 


1890 


Males 
Females 


198 
201 


9 35 
14 40 


39 
42 


30 
36 


30 
24 


143 
156 


50 
39 


5 
6 


1891 


Males 
Females 


600 

588 


40 
26 


105 
95 


133 
124 


116 
106 


70 

72 


464 
423 


120 
155 


16 
10 


1892 


Males 
Females 


464 
469 


39 
29 


63 

74 


99 
105 


90 

77 


55 
53 


346 
338 


101 
116 


17 
15 


1893 


Males 
Females 


275 
258 


24 
23 


40 

40 


55 
54 


53 
43 


34 
30 


206 
190 


61 
62 


8 
6 


1894 


Males 
Females 


252 
261 


17 
14 


50 
39 


50 
59 


42 
43 


35 
34 


194 

189 


50 

67 


8 
5 


1895 


Males 
Females 


241 
215 


16 
12 


34 
41 


72 
38 


50 

47 


27 
20 


199 
158 


36 
47 


6 
10 


1896 


Males 
Females 


201 
194 


8 
12 


34 
25 


54 
43 


32 
49 


20 
13 


148 
142 


53 

46 


6 


1897 


Males 
Females 


262 
231 


10 
15 


56 
33 


47 
46 


49 

48 


31 
30 


193 

172 


65 
54 


4 
5 


1898 


Males 
Females 


241 
265 


18 

18 


48 
40 


49 
54 


50 
57 


20 
40 


185 
209 


51 
52 


5 

4 


1899 


Males 
Females 


158 
169 


10 

8 


27 
32 


36 
34 


28 
31 


19 
16 


120 
121 


35 
39 


3 
9 


1900 


Males 
Females 


177 
122 


22 
6 


40 
22 


35 

26 


27 
14 


15 
22 


139 

90 


30 
25 


8 

7 


1901 


Males 
Females 


309 
297 


11 

18 


47 
39 


45 

47 


54 
43 


52 

48 


209 
195 


76 
88 


24 

14 



SCARLET FEVER. 645 

When Contagious. — Eichhorst says it is least contagious during the 
period of incubation, most pronounced at the time of eruption, and with 
the establishment of convalescence and advancing desquamation the power 
of contagion steadily diminishes. The average duration of the contagion 
is six weeks. 

Age. — The greater number of cases occur between the ages of 1 and 5 ; 
next in frequency, 5 to 15. Then the frequency gradually diminishes. 

Stage of Incubation. — Authorities differ as to the length of time that 
usually elapses between the exposure to the disease and the disappearance 
of symptoms. The usual rule is from a few days to a week, although 
exceptions will extend the time to several days longer. 

Eichhorst and Von Leube give it from four to seven days. Individual 
susceptibility plays an important part in scarlet fever as well as we have 
^een in other diseases. 

Henoch maintains that we cannot form an idea of the severity or 
mildness of an attack by the early symptoms. 

Table No. 96.— Statistics of Cases of Scarlet Fever Treated in the 
Riverside Hospital, Xeic Tori: City. 



Year. 


Number of T1o „ t . , Mortality 
Cases. u«MDH. Percent'. 


1903 

1904 ; Jan. to Oct. 


835 76 9.1 

718 46 6.4 



I 

Bacteriology. — The distinct specific cause of scarlet fever is unknown. 
in spite of immense scientific work. A specific micro-organism first de- 
scribed by Class 1 is a non-capsulated diplococcus, appearing occasionally in 
streptococcic form, polymorphous in character. It is constantly found in 
the pharynx in scarlatinal angina. 

Baginsky and Sommerfeld 2 found a streptodiplococcus in the pharynx 
and blood in scarlet fever, which they believe to be the etiological factor in 
that disease. As yet scarlet fever cannot be reproduced in animals, and 
hence this microbe must be looked upon as the probable causative factor. 
Owing to the immense amount of research work being done, the day is not 
far distant when the specific factor of all infectious diseases will be dis- 
covered. 

Antitoxic Substances from the Blood of Convalescing Case's of Scar- 
Jet Fever, Measles. Pneumonia, and Diphtheria. — 0. Huber and P. 
Blumenthal 3 succeeded in derivinof from the l)lood of convalescent cases in 



1 New York Medical Record. September. 1899, p. 330. 

2 Berlin Klin. Woch., Xo. 22, 1900 ? p. 588. 

* Paper read before Charity Aerzte, of Berlin, July, 1897. 



646 THE INFECTIOUS DISEASES. 

above diseases specific antitoxic substances in solution. Used in treatment 
of scarlet fever they found that the disease was shortened, the severity 
lessened; although they state they have not discovered a healing serum, 
they believe that they will be able to isolate therapeutic antitoxic sub- 
stances possessing curative properties. 

Leucocytosis in Scarlet Fever. — Dr. J. M. Bowie 1 gives a comprehen- 
sive review of the subject, and cites the results of the examination of 167 
cases with a total number of Tli counts. Of these 77 were differential to 
determine the relative percentage of the three main varieties of leucocytes. 
The following is the summary of his conclusions : — 

1. Practically all cases of scarlet fever show leucocytosis. 

2. The leucocytosis begins in the incubation period, very shortly after 
infection ; reaches its maximum at or shortly after the height or severity of 
the disease, and then gradually sinks to normal. 

3. In simple, uncomplicated cases the maximum is reached during the 
first week, and the normal generally some time during the first three weeks. 

4. The more severe the case the higher is the leucocytosis, and the 
longer it lasts; the slighter the case the slighter the leucocytosis, and the 
shorter time it lasts. 

5. A favorable case of any variety of the disease has always a higher 
leucocytosis than an unfavorable one of the same variety. 

6. The temperature has no effect on the leucocytosis. 

7. The polymorphonuclear leucocytes are increased relatively and abso- 
lutely at first, and then fall to the normal, the lymphocytes acting inversely 
to this. This cycle of events occurs in simple cases within three weeks. 

8. Eosinophils are diminished at the onset of the fever. They in- 
crease rapidly in simple favorable cases till the height of the disease is past, 
then diminish, and finally reach the normal some time after the sum total 
leucocytosis has disappeared — in short, when the poison has all been elimi- 
nated. 

9. The more severe the case the longer are the eosinophiles subnormal 
before they rise again. In fatal cases they never rise, but sink rapidly 
toward zero. 

10. The leucocytes, in complications, go through a cycle of events 
similar in all respects to that of the primary fever as regards both sum total 
and differential leucocytosis, and the same laws govern the behavior of the 
leucocytes in both cases. 

In regard to the diagnosis of scarlet fever, the simple counting of the 
leucocytes gives little aid. A differential count, however, may be of aid, 
for scarlet fever is one of the few acute infectious diseases -where one finds 



Reported in Berlin KUn. Wochenschrift. (No. 31, 1897.) 



SCARLET FEVER. 647 

an increase in the eoainophiles early in the disease and the persistence of 
that increase for some time. 

With regard to prognosis, the examination of the leucocytes seems 
likely to be of some practical value. Jn scarlatina simplex, if the case be 
severe, and the leucocytosis be high and rising, one may predict a favorable 
course ; and conversely, if it be low and stationary, one may expect a tedious 
case. Regarding the differential count, if the eosinophils show a relative 
increase, the augury is good; if they are normal or subnormal after the first 
day or two, then the case will in all probability be a severe one. Further- 
more, as long as a relative increase of eosinophils is present one cannot be 
sure that some complication will not ensue; whereas, if the eosinophils 
have come down to normal in the usual way, one may be free from anxiety 
in this respect. 

Pathology. — The gross and histological lesions found post-mortem in 
scarlet fever depend essentially upon two processes : first, the action of the 
scarlatinal toxin, associated with the changes seen in any acute febrile dis- 
ease; and, secondly, they may occur as a result of a mixed infection due 
to entrance into the organism of the streptococcus pyogenes, the staphylo- 
coccus pyogenes aureus or albus, the pneumococcus, and rarely, other micro- 
organisms. So long as the specific agent concerned in the scarlatinal infec- 
tion remains obscure, it must be impossible — in many instances, at least — 
to determine, in a given case, which of these two elements is the predomi- 
nant one. In cases succumbing early in their course to the intensity of the 
poison, before the development of secondary infections, we must assume 
the changes present to be due to the specific scarlatinal virus, while in those 
which prove fatal later, associated with grave throat lesions, streptococcic 
angina, etc., the possibility of an added etiological element in the lesions 
present after death must be admitted (Corlett). 

Symptoms. — The onset is usually very sudden. In young children the 
attack is preceded by a convulsion. Yomiting is an early symptom. 

Tongue. — The tongue has a whitish fur and the papillae will be found 
elevated and very red. It has the so-called "strawberry" appearance (see 
colored plate). The throat, especially the tonsils, will be found intensely 
congested and dry. Sometimes a severe diarrhoea is the first symptom. 
The pulse is full and rapid, from 120 to 140 beats per minute. The tem- 
perature on the first or second day is about 102° F., rarely higher. 

Glands. — Enlarged inguinal glands are a characteristic feature of this 
disease. The submaxillary lymphatic glands at the angle of the jaw are 
swollen and tender on palpation. The mucous membrane of the mouth is 
reddened. The pharynx, tonsils, and the uvula are injected. Monti 1 calls 
attention to an enanthem in scarlet fever which is seen late on the first day 



1 Jahrb. f. Kindh., vol. vii, p. 



648 



THE INFECTIOUS DISEASES. 



or early on the second. It is a diffused, mottled reddening which begins 
upon the uvula, spreads quickly over the hard and soft palate, covering the 
pillars of the fauces, and finally the mucous membrane of the cheeks. 

The Urine.— There is febrile albuminuria present, which disappears 
as the temperature declines. The urine is scanty and high-colored. 

The Rash.— This ap- 
pears usually within the 
first twenty-four hours. 
It is first seen upon the 
neck and chest — less 
often upon the small of 
the back. It is a bright 
scarlet pin-point flush, 
and occupies the sites of 
the hair follicles. The 
rash extends from above 
downward, spreading in a 
few hours to the arms; 
usually in twenty-four 
hours it reaches the 
trunk, legs, and abdomen. 
(Study frontispiece.) A 
point to note is that in 
contrast to measles and 
smallpox it is much less 
marked upon the face and 
cheeks. The immediate 
neighborhood of the nose 
and mouth remains free 
from the eruption and 
have a peculiar pallor, a 
marked contrast to the 
parts affected by the 
eruption. The dorsal 
surfaces of the hands and 
feet show the eruption. 
The palmar and plantar surfaces, though frequently injected, do not usually 
show the true punctate scarlatina rash. 

The rash shows great variations. While it may show large or small 
faintly scarlet colored patches lasting but a short time, the opposite more 
frequently occurs. When it is diffuse it may be of an intense scarlet or 
almost purple color. (See frontispiece.) It frequently shows a tendency 
to stain the tissues, and minute haemorrhages may occur with the formation 
of petechia?. 




Fig. 201. — Desquamation of the Chest. Photo- 
graphed from a Case in the Riverside Hospital. 
(Original.) 



PLATE XVI L 




■■HBIBraHHHaHai 

Strawberry Tongue in Scarlet Fever. Painted from a case in the Riverside 
Hospital. The body rash is shown in the Frontispiece. (Original.) 




Beefy Tongue in Scarlet Fever. The tongue has a glazed appearance. 
The papillae are enlarged. This type is usually seen when desquamation 
begins, after the rash has faded. Painted at the bedside from a case in the 
Riverside Hospital. (Original.) 



SCARLET FEVER. 



640 



Desquamation. — The desquamation of the skin in scarlatina begins 
over those areas on which the rash was first Been, namely, the thorax and 
neck. Thus we will frequently find evidences of desquamation on one pari 
while another part of the body has distinct traces of the rash. 

Character of the Desquamation. — On the neck, face, and trunk the 
epidermis peels off in fine, flaky scales. This is known as desguamatio 
furfuracea. This is similar to the desquamation found in measles. The 
extremities, about the hands and feet, show the characteristic desquamation. 
The epidermis peels off or can be stripped off in shreds of varying lengths. 
This is known as desquamatio membranacea or lamellosa. 




Fig. 201a. — Unusually Severe Desquamation. Willard Parker Hospital. 

(Original.) 

Duration of Desquamation. — This varies greatly and is influenced by 
the severity of the infection and the intensity of the eruption. It persists 
longest where the epidermis is thick, namely, about the hands and feet. As 
long as a single flake of necrotic shin remains, the patient may be a source 
of contagion. 

The length of time for complete desquamation may be from six to 
eight weeks. It may be of a shorter or longer duration. Eepeated des- 
quamation is not uncommon, so that we can say there is secondary and, less 
frequently, tertiary desquamation. 



Varieties. 

Toxic Scarlet Fever. — This is the most malignant form and is very 
rare. The disease is very abrupt in its onset. The temperature reaches 
105° to 107° F., and sometimes higher, within the first few hours, 



650 



THE INFECTIOUS DISEASES. 



The pulse is greatly accelerated and is weak and intermittent. The 
cheeks and lips are blanched and may show cyanosis very early. The urine 
is scanty, high-colored, and albuminous, or may be completely suppressed. 
There are marked cerebral disturbances, such as convulsions and active 
delirium. Frequently we have marked dyspnoea, the respiratory rhythm 
being short and quick, due usually not to any change in the lungs at this 
time, but probably to irritation of the respiratory centers, according to 
Ausset. Ataxic and adynamic forms are characterized by early and pro- 
found constitutional depression, due to the effect of the toxin on the nerve 
centers, the symptoms rapidly assuming a typhoidal type. 

In the haemorrhagic forms the exanthem acquires a dark purplish hue. 
Small petechias, varying in size from a pin-head to a lentil, appear scat- 
tered irregularly over the body. The blood oozes from the gums, the sputum 



PULSE-TEMP HOUR S2«*<a~'«>=.«"°«sio«S 


^ S3 « » * uj tt r* 00 & 2 ® £ = :* 2 


160 


106° - 




155 


= 




150 


105 = ' . . 




145 


LL/U-l-L-X 


1 


14-0 


,04 - = V> 1 - a\ Xj 1 \ 


u 1 


135 


1 • [ / *VTY\h 


^-J-J \-\*l 


130 


« r" _i:£tf ::_::[ 


\ 7 / \ \ \T 


125 




J. \1 


120 


_ \..u - ■ . • 

102 E 


• \l 


115 


= 1 ! ! ! Iti:mp| 





Fig. 202. — Septic Scarlet Fever with Myocarditis, Suppurative Arthritis, 
Double Purulent Otitis, General Pyaemia. Case seen in consultation in 
private practice. Child 4 .years old. (Original.) 



even being tinged with it, while epistaxis may be severe. Blood may be 
discharged from the bowels or the stools may be tarry in color. 

Bleeding is frequently seen from the genito-urinary tract or the urine 
shows the presence of blood. This form of disease is usually encountered in 
very feeble infants under 2 years of age and is invariably fatal. 

Septic Scarlet Fever. — This type is most commonly met with in chil- 
dren. The symptoms are of a more severe type. There is high and con- 
tinued fever, with involvement of the pharynx and tonsils. Prostration is 
the vital symptom showing the evidence of severer infection. There are 
marked cerebral symptoms, such as extreme restlessness, convulsions, or mild 



SCARLET FEVER. 651 

delirium. In this type we usually have persistent vomiting associated with 
general apathy. The lever rises suddenly to 11).*)° F. or 40.5° C, or higher. 
The pulse becomes very small and rapid. From .140 to 1(50 per minute, al- 
though at times 200 per minute. The thirst is extreme; the mouth being 
dry and gums parched. The throat, especially the tonsil, is deeply injected 
and frequently has scattered foci of exudate on the surfaces. The urine is 
concentrated, and invariably contains albumin. 

Scarlatina Sine Exanthemata. — Cases frequently occur in which every 
evidence of scarlet fever exists, but there is no eruption. Henoch states 
that he believes the eruption is always present and thinks that it is occa- 
sionally overlooked. The eruption is frequently of such an evanescent char- 
acter that it entirely escapes notice, but a subsequent desquamation and 
nephritis will usually strengthen the diagnosis. 

A case of scarlatina sine exanthemata was seen by me in the family of Dr. J. 
Lurie, of New York City. A child about 4 years old had been in apparent health. 
There was no history of vomiting nor any gastric disturbances. Xo history of ex- 
posure to scarlet fever. When examined by me I found no evidences of scarlet 
fever. The throat was somewhat congested, but had no patches, nor was there any 
evidences of necrotic membrane visible in any portion of the throat. The lymphatic 
glands of the neck were not enlarged. The urine was very scanty and contained 
more than 50 per cent, by volume of albumin. Blood was also present in large 
quantity. There were also hyaline, epithelial and granular casts present, when a 
drop was examined under the microscope. 

The child's urine was greatly diminished in quantity, hardly a tablespoonful 
being passed at one sitting. Diuretin and citrate of potash acted very well as 
diuretics, and later the secretion of urine was normal in both quality and quantity. 
At times it seemed as though the urine consisted of pure blood. Later the child 
developed an otitis media — which was preceded by a rise in temperature. The child 
made a good convalescence and is perfectly well to-day. 

It may be of interest to note that the child was fed exclusively by the percent- 
age method at the Walker-Gordon Laboratory. 

Scarlatina Papulosa. — Small slightly elevated papules of a dark-red 
color develop at the site of the hair follicles. They are more readily de- 
tected by the finger than by the eye, and are observed twelve to eighteen 
hours before the ordinary scarlatinal rash appears. 

Scarlatina Variegata. — This form is marked by an extremely irregular 
distribution of the eruption, frequently associated with the development of 
well-defined macular areas of an intense red color, situated at the site of the 
hair follicles, and in many instances simulating the exanthem of measles. 

Scarlatina Sine Febre. — Among extremely mild cases of scarlatina in- 
stances are frequently seen in which after a slight initial rise, the disease 
progresses without any subsequent elevation of temperature above 98.5° to 
99° F., every other symptom being present, but in a mild degree. 

Henoch reports 4 cases out of 1 <5 with irregularities of temperature. 



652 THE INFECTIOUS DISEASES. 

Fever of an inverted type has been reported by Henoch, who noted the tem- 
perature curve quite the reverse of normal, in which the temperature was 
higher in the morning than in the evening. 

Scarlatina Sine Angina. — This form of scarlatina has very slight throat 
symptoms or so insignificant as to appear almost absent. A slight conges- 
tion of the throat is visible, and usually a faint enanthem is present early 
in the disease. 

The tonsils are not enlarged, but there is an almost constant enlarge- 
ment of the papilla at the tip and edges of the tongue — an important diag- 
nostic aid. 

Complications. 1 — Scarlatina with Other Exanthemata: Mixed infec- 
tions are frequently noted. Measles, chicken-pox, or smallpox are met with. 
Corlett depicts a case of scarlatina with chicken-pox. 

I have seen a case of scarlet fever complicated with measles, in private 
practice, in consultation with Dr. Harry Weinstein, of Xew York City. 
Mixed infections have been seen many times during my service in the scarlet 
fever wards of the Eiverside Hospital — scarlet fever and whooping-cough, 
scarlet fever and measles very often, scarlet fever and diphtheria as well. 

The Throat. — Scarlatina is usually seen very early in the pharynx and 
fauces. This takes place whether we are dealing with a mild or severe in- 
fection. TVe know that certain pathogenic bacteria, such as streptococci, are 
invariably found during the course of scarlatina. 2 

Many bacteriologists agree that the Klebs-Loeffler bacillus is usually 
absent, though there are many cases of true diphtheria complicating scarlet 
fever. Several cases of diphtheritic angina have been seen by me while on 
service at the scarlet fever wards of the Eiverside Hospital. Lemoine found 
the streptococcus pyogenes in 93 cases out of 117 studied by him. The 
EHebs-Loeffler bacillus was found in addition in 5 cases of this series, and 
the bacillus coli communis in 9 cases. 

Angina Pseudomembranosa (of Streptococcic Origin). — False mem- 
branes upon the tonsils or pharynx are seen in the severe and septic types 
of this disease. It is simply a necrotic inflammatory deposit. On the second 
day the mucous membrane of the pharynx is intensely reddened and con- 
gested. The tonsils, which are much inflamed and swollen, show scattered, 
irregular patches of gray or grayish white exudate, completelv occluding the 
tonsillar crypts over a more or less limited surface. One or both tonsils 
may be affected. In many instances the pharyngeal inflammation from the 
beginning shows an extreme grade of intensity. This may spread over the 



1 "Vulvovaginitis Following Scarlet Fever" is described on page 403 (chapter 
on "Tulvo-vaginitis" ) . 

2 See elaborate clinical and bacteriological studies made by Baginsky and 
Soninierfeld, in Archiv. fur Kinderheilkunde, 1900, and Berlin. Klin. Woch., Xo. 22, 
1900, p. 588, 



SCARLET FEVER. 



653 



posterior pharyngeal 
wall, the hard pal- 
ate, and the mucous 
membrane of the 
terior surface of the 
cheek; also, to the 
posterior nares and 
the Eustachian tube, 
with resulting exten- 
of the inflam- 
matory process to the 
middle ear. There 
is a very foul odor to 
the breath, and usu- 
ally a thin acrid se- 
cretion from the nos- 
trils, causing excor- 
iation, fissures, and, 
rarely, rhagades. 

The nostrils may 
be occluded and the 
mouth held open in 
an attempt to breathe. 
Angina Scarla- 
tina Membranosa of 
True I) iphtheri 
Origin). — This 
should be regarded 
as a true diphtheritic 
complication and 
treated as diphtheria 
(see chapter on 
'"Diphtheria"' . 

Otitis. — The 
extension of the in- 
fection from the pha- 
rynx through the 
Eustachian tubes has 
already been mentioned. As a rule the younger the child, the greater the 
danger of otitis. According to Bader and Guinon, the mild or catarrhal 
form occurs in 33 per cent, of all cases of scarlet fever, and the purulent 
form is less common, occurring in 4.5 per cent, of all cases. 




654 THE INFECTIOUS DISEASES. 

Caiger, reporting 4015 cases of scarlet fever, noted ear discharge in 
11.05 per cent. In a series of 397 cases observed by me, including severe, 
malignant, and all complicated varieties, there were 82 middle ear dis- 
charges, 68 purulent, and 14 catarrhal. 

About 20 per cent, of all cases seen by me had middle ear trouble. It 
is important to have the middle ear examined when high fever persists 
during an attack of scarlet fever. Persistent high fever in a case of scarlet 
fever occurred in my private practice. It was also seen by Dr. J. W. 
Brannan and by Dr. Dench. After an examination of the middle ear, a 
thorough incision of the drum membrane liberated pus and relieved the 
temperature for a time. 

The hand will frequently be carried to the head or ear. The neigh- 
boring lymphatic glands are enlarged, palpable, and may be tender. After 
a few days, unless relieved by incision, the tympanic membrane ruptures 
spontaneously. The symptoms then usually subside. When, however, the 
inflammation becomes purulent (otitis media suppurativa), then the con- 
dition is serious, owing to the possibility of deafness arising. 

Empyema of the mastoid antrum, 1 resulting from chronic suppurative 
otitis media, occurs in a small percentage of cases. With the establishment 
of a communication between the tympanic cavity and the cells of the mas- 
toid, there is usually a slight decrease in the amount of discharge from the 
ear. The temperature rises to 104° F., or higher, and shows a marked 
fluctuation of a remittent character. There may be rigors. If old enough 
the child will complain of pain in the mastoid region with tenderness on 
palpation over the mastoid process. 

The pulse becomes rapid and irregular. These symptoms continue from 
day to day, and unless an operation is performed these cases will end fatally, 
due to the development of meningitis. 

More rarely an inflammatory swelling appears behind the external 
ear — situated over the mastoid — associated with a rise of temperature, local 
tenderness, with more or less forward projection of the ear ; and occasionally 
local suppuration, with abscess formation, takes place. 

A case of this kind occurred in the private practice of Dr. R. W. Reid, of New 
York City, with whom I saw the case in consultation. The child had a very severe 
attack of scarlet fever. It was of a septic character. Necrotic membranes could be 
seen over the pharynx and tonsils. There was persistent fever. The child was 
decidedly rachitic. The case was complicated with an acute nephritis. The urine 
was very scant and was loaded with albumin and casts. Later the right ear dis- 
charged pus very freely. 

When I saw the child there was a superficial swelling over the mastoid which 
pushed the ear forward. The inflammatory condition was local and due either to 



Read article on mastoid (chapter Otitis) page 857. 



SCARLET FEVER. 655 

periostitis or to a local adenitis, remotely dependent on the middle car suppuration. 
An incision made liberated a Large quantity of pus. The child died of general septi- 
caemia following toxic nephritis. 

Angina Ludovici (Tippet Neck). — This may occur about the fifth day 
of the disease, though more commonly seen early in the second week of the 
attack. 

The skin is indurated, glossy, and may pit on pressure, though it may 
give no sense of fluctuation. The process may be limited to the angle of 
the jaw or involve the entire neck; it may extend downward to the clav- 
icles and upward along the sides of the face and head, rendering the head 
almost if not wholly rigid. The diffuse cellulitis of the deeper tissues con- 
stitutes one of the gravest complications of scarlet fever, proving almost 
invariably fatal. Death results from a rupture of one of the large vessels, 
the jugular vein or internal carotid artery, or, as a result of thrombosis 
or embolism, with fatal meningitis or pyaemia. The greater the toxaemia, 
the more pronounced the lymphatic enlargement. 

The Lymph Glands. — The neighboring glands are enlarged and tender 
on palpation. The infiltration of the glands may be extreme, and in rare 
instances an excessive infiltration of the cellular tissue of the neck occurs, 
which becomes hard and indurated, and occasionally renders the head im- 
movable. 

Phlegmonous Inflammation of the Neck — Diffuse Cellulitis. 1 — Scham- 
berg studied the glands in 100 cases of scarlatina. He found the maxillary 
glands enlarged in 95 per cent, and the submaxillary glands enlarged in 36 
per cent, of his cases. The posterior cervical glands were found enlarged 
in 77 per cent, of the cases. Sometimes the parotid glands are also in- 
volved. Frequently the inflammatory condition persists and suppuration 
occurs, resulting in so-called phlegmonous inflammation. Even when freely 
incised there is danger of pus burrowing beneath the connective tissue. 
Sometimes a rapid and diffuse cellulitis with excessive infiltration of the 
deeper tissues is associated with the suppurative process. 

Retropharyngeal abscess occurs occasionally. 2 Bokai found 6 cases out 
of 664 cases of scarlet fever. 

Schamberg, in a study of the lymphatic glands in scarlatina, found the 
various groups enlarged in the following proportion in 100 cases : — 

Inguinal glands 100 per cent. 

Axillary 96 per cent. 

Maxillary 95 per cent. 

Posterior cervical 77 per cent. 



'•Schamberg: Annals of Gynaecol, and Pediatry, December, 1889, vol. viii, p. 39. 
2 Jahrbuch f. Kinderheilkunde, vol. x, p. 108. 



656 THE INFECTIOUS DISEASES. 

Anterior cervical 44 per cent. 

Submaxillary 36 per cent. 

Epitrochlear 26 per cent. 

Sublingual 25 per cent. 

As a result of the analysis of these 100 cases he finds that the maxillary 
glands commonly attain the largest size, and also most frequently "undergo 
suppuration. In all cases examined on the second and third day of the 
disease the enlargement of the lymphatic glands was well marked. 

Scarlatinal synovitis (so-called scarlatinal rheumatism or pseudorheu- 
matism) is occasionally met with. Ashby 1 met with this condition in 2 per 
cent, of his cases. 

Hodge found synovitis in 117 out of 3000 cases studied, or 3.2 per 
cent. There are two distinct forms: — 

(a) Simple catarrhal or serous synovitis. 

(b) Suppurative or purulent arthritis. 

The streptococcus pyogenes has been found in both forms in pure 
culture and combined with other micro-organisms. 

This complication occurs more often in children over 5, and is rarely 
met with in children under 3, according to Holt. 

The symptoms met with are: Pains in the affected joints, swelling, 
which may or may not be marked with slight impairment of motion, some 
redness, and a slight rise in temperature. 

Owing to an effusion of serum, large joints, such as the knee and 
shoulder, remain swollen many weeks. When suppuration develops in the 
involved joint, Henoch claims that it is due to emboli, following septi- 
caemia. 

The Kidneys. — There are three forms of involvement of the kidneys in 
scarlatina : — 

1. Transient febrile albuminuria and the interstitial catarrhal ne- 
phritis. 

2. Septic nephritis. 

3. Post-scarlatinal nephritis. 

Transient albuminuria occurs in three-fourths of all eases of scarlet 
fever. It does not differ from a "febrile albuminuria" seen in all acute 
infectious diseases associated with high temperatures. It has no special 
significance. 

Catarrhal nephritis not infrequently occurs in the first week in cases 
of moderate severity. The urine contains, besides albumin, degenerated 
epithelial cells, mucous cylindroids, and rarely epithelial or even hyaline 
casts, occasionally a few red and white corpuscles. 



British Medical Journal. 1883, vol. ii, p. 514. 



BCAKLET FEVER. 



G57 



Clinically, we have slight evidence of oedema. Pathological changes 
frequently take place without a trace of albumin or without the presence of 
Such cases have been reported. 1 

Where the scarlatinal virus causes a general tox- 
aemia, and we have grave throat symptoms accompanied by necrotic de- 
posits on the tonsils and pharynx, there are always swollen glands. Xe- 
phritis develops from the intensity of the infection caused mainly by the 
streptococcus pyogenes. In many instances death occurs before well-de- 
fined symptoms of nephritis are made out. In such cases there is no 
dropsy and uremic symptoms are absent. In rare in stances the urine is 
normal during the entire attack until a post-mortem shows the existence 
of nephritis. 



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Fig. 204. — Septic Nephritis from Riverside Hospital. 

Post-scarlatinal Nephritis. — When the acute symptoms subside and 
nephritis develops it is called post-scarlatinal nephritis. This nephritis is 
not always glomerular. Jurgensen's statement that the effect of the in- 
flammatory irritant depends not only upon its virulence (toxicity), but 
upon the length of time during which it acts upon a given local site, is 
extremely interesting and important. 

Symptoms. — The symptoms may be sudden, although if daily exami- 
nations of the urine are made, a gradual diminution in the quantitv se- 
creted in twenty-four hours will be noted. 

The child who has seemed apparently well and convalescing becomes 
pale, is restless and irritable, and if old ecough, complains of headaches, 



Corlett : 



'Treatise of Infections Exanthemata,"' p. 201. 

42 



658 



THE INFECTIOUS DISEASES. 



thirst, and loss of appetite. Constipation may be present. Vomiting is 
usually an early symptom of nephritis. 

The earliest symptoms of nephritis are: rise of temperature, occur- 
rence of oedema, however slight, involving particularly the lower eyelids, 
with distinct puffiness of the eyes. Sometimes the whole face is swollen 
and bloated. The feet and legs are (Edematous, so also the scrotum and 
penis in the male, and the labia majora in the female. Such oedema may 
also be seen on the dorsum of the feet and upon the knuckles. There is 
pitting on pressure. 

ROUND EPITHELIAL CELLS red BLOOD CORPUSCLES 
PROBABLY FROM CONVOLUTED | j 

^ EPITHELIAL AND 

I PUS CAST 



GRANULAR 

cast; 




EPITHELIAL 

CELL 
PROBABLY FROM 
VAGINA 



HYALINE CAST 



PUS CORPUSCLES 
Fig. 205. — Drop of Urine from a Case of Post-scarlatinal Nephritis. Original 
drawing from a child seen in consultation by the Author. 

The urine is greatly diminished in quantity, so that several teaspoonfuls 
only may be passed in twenty-four hours. The reaction is acid. Specific 
gravity is from 1.006 to 1.065, the latter being rare. The amount of urea 
is under 2 per cent. Albumin is present from 0.5 to 1 per cent, and 
higher. The diazo reaction is of no value in scarlet fever. 

Microscopically. — There may be present hyaline, epithelial, granular 
and blood casts, fragmented renal epithelium, white and red blood-corpus- 
cles; the latter in varying numbers; uric acid and oxalic acid in crystal- 
line and amorphous form, and more or less granular debris. 

Cases are seen now and then in which almost normal conditions of the 
urine prevail and still nephritis exists. 

Nephritis usually exists a few weeks, although obstinate cases may 
continue for months and even years. 



SCARLET FEVER. 



659 



Great care should be exercised in giving the prognosis in cases of post- 
scarlatinal nephritis. Uraemia, when occurring during nephritis, is a grave 
symptom. It is usually preceded by vomiting, stupor, and peculiar twitch- 
ings of the facial muscles. 

The pulse is slow; the temperature subnormal; the tongue is dry. 
Sometimes just the reverse exists and there is high fever, very frequent 
and small pulse; the respirations are short and hurried, and the skin is 
dry. 




Fig. 206. — The Heart in a Case of Scarlet Fever : a. a., Parasternal line. 
6. &., Mammary line, c, Apex. x. x. x. x., Location of murmur. From 
Author's service at the Riverside Hospital. 



Convulsions may develop, clonic in character, of varying intensity, in- 
volving the face and extremities as a whole. Sometimes only distinct 
groups of muscles are involved. Cyanosis is marked, complete suppression 
of urine follows, coma ensues, and usually these cases end fatally. 

Anasarca is frequently associated with or subsequent to oedema. We 
frequently have serous exudations into the serous cavities — pleura, pericar- 
dium, or peritoneum. (Edema of the lungs, sometimes oedema of the larynx, 
results, and is usually fatal. Mayr mentions oedema of the pia mater and 
ventricles of the brain. 

The heart requires careful watching in scarlet fever. Its great sus- 
ceptibility to the toxin and the danger of paralysis should be remembered. 



660 THE infectious diseases. 

The heart-sounds may lose their normal tone, the first sound becoming soft 
and valvular, or they may run together. We have in the beginning tachy- 
cardia (increased heart's action), later bradycardia (slowed heart's action). 
These symptoms point to an existing mild myocarditis, according to Born- 
berg. 1 

In some cases pericarditis or endocarditis may develop. In the ma- 
jority of cases the endocardium of the heart wall, rather than the valves, is 
involved. 

The Lungs. — In addition to the oedema previously mentioned, bron- 
chitis frequently accompanies scarlet fever. Broncho-pneumonia is also 
frequently noted. Henoch believes bronchial involvement is frequently 
overlooked. It is no doubt due to accidental transmission of septic mate- 
rial from the throat into the trachea and lungs (so-called Schluck-pneu- 
monie). 

It may also be the result of direct infection through the blood-vessels, 
a part of the general sepsis. 

Acute croupous pneumonia occurs more frequently in cases in which 
scarlatinal nephritis exists. 

Pleura?. — Scarlatinal poison seems to affect the serous membranes of 
the body, so that inflammation of the pleura is by no means rare. It is 
usually seen during the second week of scarlet fever and is unilateral. When 
excessive exudation exists we must watch the case carefully, as a fatal ter- 
mination is by no means rare. Empyema was seen by me as a complication 
of scarlatina at the Eiverside Hospital. 

Gastrointestinal Tract. — Early in the disease, through infection, very 
young children have stomatitis — ulceration of the mucous membrane of the 
mouth and cheeks seriously interfering with nutrition. Actual gangrene 
can occur. See chapter on "Noma/ 5 for the case reported by me. 

Diarrhcea and vomiting are frequently noted. Both are early symp- 
toms. Diarrhoea may be : — 

(a) A simple catarrhal enteritis. 

(6) Dysentery with bloody, purulent stools. 

(c) Of a typhoidal character — watery stools with marked tympanites. 

Liver. — Enlargement of the liver sometimes occurs. Sometimes at- 
rophy has been noted. Icterus is frequently seen, though it disappears with 
convalescence. Baginsky maintains that when icterus exists with nephritis, 
it is to be dreaded particularly as predisposing to the danger of uraemia. 

General furuncidosis or multiple abscesses are occasionally seen. They 
are usually met with in children with severe systemic infections, having low 
vitality. 



a Ernst Romberg: "Ueber die Erkrankungen des Herzmuskels bei Typhus Ab- 
dorninalis, Scharlaeh, tmd Diphtheric/' Deutsch Archiv. fur klin. Med., vol. xlviii, 
1891, pp. 369 et seq. 






SCARLET FEVER. 661 

A case of this kind Mas seen by me in consultation with Dr. Glass of New York 
City, in which a child, very rachitic, developed multiple abscesses in almost every 
joint in the body. 

Such cases invariably end fatally. 

The spleen is frequently enlarged and readily palpable at the margin 
of the ribs. In some cases it is double its normal size. 

Sequelae. — Tuberculosis rarely follows scarlet fever. Frequently pro- 
found anaemia is seen. Occasionally true diphtheria follows, leaving chronic 
enlargement of the tonsils or chronic inflammatory changes in the pharyn- 
geal and nasal mucous membrane. 

Forchheimer 1 has reported persistent ozama as a sequela to scarlet fever. 
Total deafness or partial loss of hearing is one of the most common sequela} 
of this disease. 

Chronic nephritis and endocarditis, with resulting permanent lesion 
of the mitral valves, frequently follow scarlet fever. 

Gangrene of Arms and Legs After Scarlet Fever and, Other Infec- 
tious Diseases. — Eichhorst 2 reports the case of a 4-year-old girl who had an 
unusually severe attack of scarlet fever. At the end of the third week signs 
of embolism of the popliteal artery suddenly appeared in the left foot and 
leg. Gangrene progressed until the line of demarcation was sharply ex- 
hibited above the lower half of the leg. Amputation was performed and 
the child made a good recovery. A thrombus was found in the left popliteal 
artery 1 centimeter above its bifurcation, extending into both the anterior 
and posterior tibial arteries for the same distance. The popliteal artery 
showed signs of endarteritis. Pure cultures of the streptococcus pyogenes 
were found in the pus from a left-sided otitis media and from an abscess 
on the forehead. 

Only two other cases of gangrene following scarlet fever are reported 
in medical literature. Both lower extremities were involved in these cases, 
which occurred in boys aged 4 and 9 years respectively. In all, 166 cases 
of gangrene occurring in infectious diseases were collected, and of these 
typhus (42), typhoid (40), and influenza (19) furnish the largest number. 
Five followed measles, 1 diphtheria, and 1 varicella. 

Post-operative scarlatina is met with occasionally. Sir James Paget 
believes the patients were infected before the operation. Hoffa 3 says that 
these should be termed post-operative scarlatinoid erythemas. A case of 
this kind was seen by me during the winter of 1902. 



1 Article on "Scarlet Fever" in "Twentieth Century Practice of Medicine," 
1898, vol. xiv, p. 80. 

2 Deut. Archiv. f. klin. Med., vol. lxx, Nos. 5 and 6. 

3 In Von. Volkmann's Sammlung Klin. Vortrage, No. 292 ; Chirurgie, No. 90, 
1886-1887, p. 2679. 



362 



THE INFECTIOUS DISEASES. 




Fig. 207. — Post-operative Scarlatinoid Erythema. (Original.) 

A child, 7 rears old, was taken to the Manhattan Ear and Ere Hospital and 
operated for hypertrophied tonsils, by Dr. N. F. Chappell. The case was given the 
usual aseptic care. Two days later I saw the bov with a well-denned scarlatina 



SCARLET FEVER. 663 

covering liis whole body. The mot her assured me that the boy was not exposed 
to any infection, excepting while waiting in the dispensary with other patients. The 
otitis media and necrotic pseudo-membranes on the tonsils, also desquamation! cer- 
tainly completed the clinical picture and strengthened the diagnosis. 

The Diagnosis. — When fever exists accompanied by an inflamed 
throat and an eruption over the body, then the diagnosis of scarlet fever 
can be made. Later on we have desquamation. The most charac- 
teristic early symptoms of a typical scarlet fever are: Intense redness 
of the fancial mucous membrane, sore throat, early and persistent 
vomiting, fever, thirst, and increased pulse rate. The tongue is very 
characteristic — strawberry appearance. (See Plate XVII.) Sometimes 
an attack of scarlatina is ushered in by convulsions. Older children 
complain of an intense headache. There is marked constitutional 
depression and aching of bones. Von Leube maintains that vomiting 
occurs more often as an initial symptom in this than in any other 
disease, excepting pneumonia, There is nothing peculiarly characteristic 
in the early temperature of scarlet fever. It remains elevated after a 
sudden rise, and subsides gradually by lysis, toward the end of the first 
week. 

Drug Eruptions. — Great care must be taken to learn if a child has 
received belladonna^, opium,, quinine, or antipyrin. These drugs give an 
eruption similar to scarlet fever. We should always learn if such drugs 
have been given before making a positive diagnosis. 

Course. — Scarlet fever usually runs its course in about six weeks from 
the beginning of illness. The disease is spread by the walking cases who 
have not completely desquamated. It is also spread by cases in the early 
stages of the disease. Such children usually complain of headache, nausea, 
and vomiting. A superficial examination or a careless examination of these 
"spoiled stomachs" has frequently been the cause of the spread of scarlet 
fever, children being permitted to go to school. In the pre-exanthematous 
type the diagnosis is difficult unless the throat is carefully inspected. No 
child should be permitted to attend school until the last evidence of desqua- 
mation has disappeared. 

Prognosis. — It is very difficult to determine the outcome of a case, 
especially at the beginning of scarlet fever. A mild rash may have serious 
complications and a severe rash may run a very mild course without com- 
plications. Individual susceptibility plays an important part in forming 
an opinion as to the outcome of any case of scarlet fever. The following 
symptoms should influence an unfavorable prognosis: continued hyper- 
pyrexia; continued vomiting; delirium or other cerebral symptoms, such 
as convulsions or stupor; an irregular anomalous or poorly developed rash, 
if intense, suggests extreme virulence; an extremely rapid and feeble or 
irregular pulse. Great stress should always be laid on the condition of the 



664 THE INFECTIOUS DISEASES. 

heart. Other complications, such as broncho-pneumonia, or diphtheria, or 
kidney disease, should be noted as very serious complications. 

Treatment. — Isolation and Care: The first thing to do in a case of 
scarlet fever is to isolate and remove all healthy children and adults. The 
patient should be given in charge of a competent nurse. The best method 
of isolation is to have one or two rooms on the top floor, with a southern 
exposure. The nurse should have a cap completely covering her hair. Her 
uniform should be thoroughly boiled after using. All linen, such as hand- 
kerchiefs, bed linen, etc., should be disinfected by soaking in 1 to 2000 
bichloride solution before being washed. I have always used the Japanese 
paper handkerchiefs; they are convenient to wipe the secretions and dis- 
charges from nose and mouth, and can be burnt when soiled. 

A sputum cup or cuspidor, containing a 5-per-cent. solution of car- 
bolic acid, is very useful. The urine and faeces can be disinfected by adding 
either a saturated solution of copperas to it or by mixing Javelle water, the 
ordinary Labarraque's solution of chlorinated lime. 

The physician in attendance should protect his clothes by wearing a 
gown which he removes on leaving the patient's room. He should walk in 
the open air at least an hour before calling elsewhere. 

Hygienic Treatment. — The temperature of the room should be from 
68° to 72° F. Fresh air must be admitted; hence proper ventilatici is 
imperative. In winter the patient should be well protected from draughts. 
Sunshine is imperative, although the eyes should be shielded from direct 
sunlight. A tepid sponge-bath can be given every morning, and also in the 
evening, especially if there is profuse perspiration. The child's linen should 
be changed once a day. When the eruption causes itching, the body should 
be rubbed with cold cream, carbolated vaseline, or the following recipe is 
very useful : — 

IJ Calamine 1 drachm 

Ung. aq. rosar 1 ounce 

M. ft. ungt. 

Sig.: Apply over the body once or twice a day. 

Forchheimer advises the addition of menthol, 1 per cent., to relieve 
itching. This can be added to the above. 

General Treatment. — Stimulate the Emun dories: The bowels should 
always receive attention, whether constipated or not; a dose of calomel or 
several wineglassfuls of citrate of magnesia or villacabras, in wineglassful 
doses, three times a day, will be found very serviceable. 

Lemon juice in the form of lemonade is very serviceable in stimulating 
the secretion of urine, and also for quenching thirst. The citric acid cer- 
tainly has a beneficial effect on the throat. 

I have always seen the best results from keeping the bowels loose and 



EM A&LET FEVER. MM) 

ihr kidneys active. That we eliminate toxic products in this manner no one 

can deny, and we certainly can do no harm by this preliminary treatment. 

Fever can also be reduced by the use of the following mixture: — 

IJ Tinct. aconite 20 drops 

Spir. mindereri 2 ounces 

Syr. limonis 1 ounce 

M. Sig.: Teaspoonful every hour until sweating is produced, for a child 5 to 
12 years old. Younger children one half the dose. 

Weak Pulse. — When the first sound of the heart becomes weak, or the 
two sounds lose their normal tone, stimulation must be commenced. The 
same is true if the pulse is weak; 1 / 100 grain of strychnine can be given 
every three hours, or oftener, if necessary. It must be borne in mind that 
children tolerate strychnine in toxaemic conditions in very large doses. It 
is a good plan to give coffee with the strychnine or to combine it with caf- 
feine or musk. Digitalis is indicated if the pulse is weak and of low ten- 
sion. Champagne or whisky is tolerated in extremely large doses. Henoch 
considers camphor one of the best stimulants when given hypodermically 
every two or three hours : — 

B Camphor 1 gram 

Ether 10 grams 

Sig.: Use hypodermically. 

Coma. — In coma the subcutaneous use of sodium-carfeine-benzoate 
stimulates the heart and arouses the child from stupor. It also stimulates 
diuresis. When bloody urine exists in addition to gallic acid, suprarenal 
extract or its alkaloid, adrenaline, can be used in very small doses. 

Digitalis should not be used continuously, as it irritates the stomach. 
and in its stead tincture of strophanthus should be used. 

Spartein sulphate, 1 / 4 to 1 / 2 grain, injected hypodermically, with dis- 
tilled water, is useful in cardiac weakness. When meningeal symptoms, such 
as delirium, cannot be relieved by hot baths, and bromides internally; then 
the application of several leeches behind the ears, over the mastoid, will be 
very useful. 

Nephritis. — When the first symptom of nephritis appears we must aid 
the kidneys, skin, and bowels by eliminative treatment. In this manner 
only can the blood pressure be reduced. The child must be kept in bed, 
well blanketed. The diet should consist of milk, milk and seltzer, milk and 
cereals, and buttermilk. If the stomach is irritable then the milk should 
be peptonized. When extreme repugnance to milk exists, then chocolate 
may be substituted or some vanilla flavor added to the milk. For thirst 
give whey, lemonade, or orangeade. To stimulate diaphoresis, hot baths 
aided by hot packs will be serviceable. The temperature of the bath should 
be 100° to 110° F. The child is immersed from five to ten minutes. The 
surface of the body must be continually rubbed during the bath. The pa- 



. . . 



THE INFECTIOUS D> - - 



fient when taken out of the bath is placed between hot blankets for one 
hour, so as to aid diaphoresis. To give the hot pack the child should be 
wrapped in a blanket wrong out of hot water, temperature 100° F-. and 
then coTered with a dry blanket, oyer which is placed a robber cloth. The 

imlm :.m ils: i .mil mm ::1 mm 

mi '_- m fmmi 'r minimi innim :m im. mi mi mil mmli 

:.: :::: i mm mi Id -:p :: 
m.immi im-im. 

mi : li:_l 1 in ml mi ::"t: 
mm m : iimmm ] n minr 
side place hot-water bottles 
or hot bags of sand so pro- 
m:mi ill.: ±1 :1ml i :m:: 1-e 
burned. Over these place a 
rubber cloth or a rain coat. 
. mr ill ml ir ill :i imimr 
blanket. Sweating occurs rery 
nm mi mm mi mm m :1m 
manner. In an emergency 
:ln :mmm im-mi: im :- 
mm immii :: mi m>— mi: 
bottles, for a hot-air bath. 

?il: :m:m mi ;'i": mmli 
are such cardiac depressants 
that they ire merely men- 
r: :i7 1 _ : n : mimmim 
1 m m :mm is ferj Yam- 
: li ~li- : mnmil '-_-"«- 
; nmm mi mi : im> 
rlm im: mi iimn iimiiis 
mm ' r ' :mi in mini ~m-r. 




: t rilimi-i z~ m 



m :m :i: : " m 
imrisi? is immm 
:1I. mi mmmllv 



; : : mi 



SCARLET FEVER. 

drug should be given at least thro* stimulate the kidneys. 

Another drug highly recommended by Prof. Baginsky is theocine. It can 
be given in the same dosag - iiuretine and the dose repeated several times 
a day. This drug will produce a copious flow of urine, and can be recom- 
mended because it does not disturb the stomach. Xow and then I have 
noticed that marked vomiting followed the administration of almost any 
drug during the course of nephritis ; hence great care should be taken not 
to be prejudiced and condemn a drug during the course of nephritis with 
toxic or uremic symptoms, if the patient vomits. 

v - . — When the kidneys are affected, their activity is 

diminished, and an ex<_ ss salt is st <:1 in the tisfi s. As each molecule 
of salt requires a certain quantity of water to hold it in solution, such water 
will be abstracted from the tiss - _ ngiise tc :he dropsical condition. By 
giving a diet, which is free from salt, we can decrease the edema. 

Restorative treatment, such as iron, strychnine, malt extract, and cod- 
liver-oil should be given after the symptoms of nephritis subside. The 
child should be kept well protected for at least two months after the first 
symptoms appear. 

As soon sfi the temperature falls to the normal point we can give : — 

R Mist, ferri et ammonii aeetatis 1 fluid ounce 

Glyeerini 1 fluid ounce 

Aquae ... q. s. ad 4 fluid ounces 

If. Sig.: A teaspoonful or more every three hours, in water. 

Or Bashanr s mixture may be given : — 

R Tinc-t. ferri ehlorid. 

Acid, acetic dil.. of each 1 fluid drachm 

Liq. ammonii acetat 6 fluid drachms 

Aquae q. s. ad 6 fluid ounces 

If. Sig. : Tablespoonful three times daily for a child six years old. 

docarditis or Pericarditis. — The heart requires careful watching, 
especially if symptoms of rheumatism appear. Sudden death will fre- 
quently occur from heart failure. 

ae of this kind was seen by me in consultation with Dr. S. Straus ::' New 
York City, in which a child desquamating with scarlet fever, had myo- and endocar- 
ditis. There was a general anasarca. The pulse became \ery weak during the hot-air 
bath. The child died suddenly. It is verv apparent, therefore, that the hot-air bath 
is not without its dar . 

Otitis. 2 — The escape of pus from the external auditory canal is by no 



Medical du Xord. January 2 " 2 5 

Read also chapter on "Acute Otiti- 



668 THE INFECTIOUS DISEASES. 

means rare. The extension of a streptococcus inflammation from the 
pharynx through the Eustachian tubes can sometimes be aborted by local 
treatment. Too great stress cannot be laid on the active antiseptic treat- 
ment of the nasopharynx as a means of prophylaxis. When earache occurs, 
no matter how slight, then the ears should be examined. It is better to call 
an aurist to make sure of the diagnosis and treatment, rather than risk the 
dangers of mastoid inflammation, with the possible extension of a menin- 
gitis and a fatal outcome. Until then, local treatment such as the appli- 
cation of a hot-water bag to the ear, or cotton, inserted into the ear, will 
afford temporary relief. The danger of using cocaine should not be for- 
gotten, although it is a valuable remedy. When pus is evident, as shown 
by the bulging of the membrane, then a paracentesis should be performed, 
and the cavity irrigated with boric acid solution, or equal parts of hydro- 
gen peroxide and sterile water. The ear should not be packed with gauze, 
but should be permitted to discharge and drain freely. Eestorative treat- 
ment, such as has been previously mentioned in conjunction with nephritis 
in this chapter, is indicated. 

Diet. — Generally speaking, during the febrile stage and until the end 
of the second week, an exclusive liquid diet of milk or milk and barley 
water should be given. If milk is not well digested then whey should be 
tried (see "Dietary''). Later, beef soup, mutton or chicken broth, butter- 
milk, all gruels, fruits, fruit jellies, toast, weak tea, weak coffee, cocoa, and 
chocolate. For thirst — Appollinaris, Vichy, and lemonade. The tendency 
to nephritis seems to be lessened by giving our patients a milk diet, hence 
this fact must be borne in mind. Steak juice and egg albumin, diluted 
with water, can be given later on. 

Serum Treatment. — Antistreptococcus serum has been extensively used. 
It has its opponents and some who extol its virtues. Baginsky 1 reports a 
series of 48 cases treated with serum, of which 7 were fatal, a mortality of 
14.6 per cent. 

A clinical study of the value of antistreptococcus serum was reported by 
me 2 in a paper read before the Section on Pediatrics of the Xew York 
Academy of Medicine. 

Antistreptococcus serum (Aronson's 3 ) was sent to me in the winter 
of 1902-1903. The serum proved very successful in a series of cases in my 
private practice. 4 

Through the courtesy of Professor Escherich I saw a number of cases 



1 Berlin Klin. Woch., 1896.. Xo. 33, p. 340. 

2 See "Value of Antistreptococcus Serum," May 12, 1898. Published in 
Archives of Pediatrics (Louis Fischer). 

3 1 am indebted to Messrs. Schering & Glatz for sending me sufficient serum 
for clinical trial. 

4 See my article in the Xew York Medical Record, March 7, 1903. 



SCARLET FEVER. 



669 



that were treated by Noser's antistreptococcus serum at the Children's Hos- 
pital in Vienna while in Europe in May, 1903. 

All of these serum cases did remarkably well. 1 was impressed by the 

excellent results, especially by the distinct fever crisis, after the necessary 
dose of sent in was injected. The streptolytic serum made by Steam is well 
worth trying in severe scarlet fever. 

The following case 
occurred in my private 
practice : — 

Hannah S., 8 years old, 
was first seen by me Febru- 
ary 20th, in consultation 
with Dr. L. Kohn. The his- 
tory given me was that the 
child had been sick three 
days, with a temperature of 
104° F. the day previous and 
104 7,° F. to-day. The pulse 
was weak and rapid. Large 
necrotic patches covered the 
entire surface of the 
pharynx, tonsils and uvula. 
There was a marked foetor 
of the breath. A very in- 
tense eruption covered the 
entire body. Diagnosis : 
Scarlatina. There was a 
loss of appetite and a gen- 
eral apathetic condition. At 
the time of the injection of 
the serum, the following con- 
dition was noted: Tempera- 
ture 104 V 5 ° F., pulse 138, 
respiration 26. Owing to 
the severe general infection, 
I decided to give an injection 
of 20 cubic centimeters of 
antistreptococcic serum. On 
February 23d. I saw the case 
a second time with Dr. 
Kohn and noted the entire 
disappearance of the ne- 
crotic patches in the throat 



DATES OF OBSERVATIONS 




4 


5 


6 


7 


8 


9 


10 


Cent. 


Fahr. 


AM>M 


am:pm 


AM 


PH 


am:pm 


AMCPM 


am!pm 


am:pm 


41°~ 


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: 106°'2 


: 
















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per minute 


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3^j 


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35 


|? 


Respiration* 
per minute 




cyJN 


OJN 


Hoc 









Fig. 209. — Temperature Chart from a Case of Scar- 
let Fever Treated with Antistreptococcus Serum. 
(Original.) 

The attending physician told me that this condition 



was already apparent on the third day after the serum injection 

The specific action of antitoxin in diphtheria is far greater compara- 
tively than the action attained from the use of this antistreptococcus serum. 
The clinical results were certainlv striking. 



g70 THE INFECTIOUS DISEASES. 

The Temperature. — The effect of the serum on the temperature show? 
that it did inhibit bacterial products. Within twelve to twenty-four hours 
after the serum injection I have seen a distinct crisis in the temperature. 
In other cases the temperature was gradually reduced by lysis. (Fig. 209.) 

Another interesting observation in most cases is the disappearance, 
almost melting away, of the necrotic membranes after the fourth day. The 
glands of the neck were swollen and subsided with the disappearance of the 
throat manifestations. The vital point consisted in a strengthening diet in 




Fig. 210. — Method of Nasal Syringing employed in the Scarlet Fever 
Ward of the Riverside Hospital. (Original.) 

addition to strict hygiene. I feel warranted in advocating the use of this 
new serum in fhe treatment of scarlet fever. 

Medicinal Treatment. — The Throat: When children are old enough 
to use a gargle they should be given a mild antiseptic solution such as table- 
salt solution, using a pinch of salt to a wineglassful of lukewarm water. 
Gargle every hour. 

A spray consisting of 1 to 2000 bichloride directed against the pharynx 
and tonsils every hour is useful. If spraying is difficult, then swabbing the 
throat with cotton dipped in bichloride is equally good. High temperature 
will frequently subside if the nasopharynx is properly irrigated. 

The septic accumulations are very serious and cause profound toxaemia 
unless cleansed thoroughly. 



SCARLET FEVER. G71- 

Warm solutions of 1 per cent. Lehthyo] repeated every six hours arc 
recommended by Seibert. Local applications of :>() p.-r cent, resorcin solu- 
tion in alcohol, applied on cotton several times a daw arc also advised. 

Nasal Douching. — My preference has always been for mild saline 
douches. Hold the child firmly and cleanse the oares with a nasal tip 
attached to a fountain syringe, at a height of no more than two feet. Per- 
manganate of potash, several crystals to a pint of water, is very good when 
there is foetor. 

Sulphurous acid has been strongly advocated by some. I saw some 
excellent results from its use while on duty at the hospital during the sum- 
mer of 190*2 in necrotic scarlatinal angina. 

Sulphurous acid has been used by me and certainly can be recom- 
mended when extensive necrotic patches exist : — 

B Acid sulphurous (U. S. P.) 1 drachm 

Aquae 8 ounces 

M. Sig. : One teaspoonful every two or three hours. 

When the acid used is of full strength, allow it to stand a few minutes 
before giving it to the patient, so as to permit the gas to escape ; otherwise 
it will be too irritant. 

If it is refused an injection can be made with a small glass syringe, 
throwing the medication as far back as possible. 

I£ Natrium sozoiodol, 

Flor. sulphur of each, equal parts 

M. For insufflation into the nostril three or four times a day. 

This seemed to exert a very beneficial effect on the necrotic tissue, 
causing a clearing of the throat. 

If the treatment causes nausea or vomiting, then the sozoiodol natrium 
can be given internally in the following manner: — 

R Xatrium sozoiodol 2.0 

Aquae 100.0 

M. D. Sig.: Teaspoonful every hour. 

Swollen Lymph Glands. — In septic scarlet fever with necrotic pseudo- 
membranes in the throat, the adjacent lymph glands will be swollen. 

At times there is an extensive oedema and infiltration extending into 
the glottis which can result in asphyxia. 

Such cases will be benefited by the use of thorough inunctions of 
Crede ointment. 1 It must be distinctly understood that no result will be 
noted unless the ointment is rubbed into the swollen glands at the angle 
of the jaw for at least fifteen minutes. This can be repeated several times 
a dav. 



1 Schering & Glatz, agents, New York City. 



672 THE INFECTIOUS DISEASES. 

I also have used inunctions along the spine to promote absorption over 
a greater area. This has proven very efficacious in many cases. 

Forchheimer advocates the use of sterile normal salt solution subcu- 
taneously. This is done to stimulate diuresis and also to aid in the elimi- 
nation of toxins. In my own practice I have found marked benefit from 
irrigating the colon with a rectal tube introduced about six inches, using 
several pints of normal salt solution at a temperature of 110° to 115° F. 
This is a very rapid and convenient method in an emergency, especially 
when one is hampered by necessary irrigators and needles, as we require 
only an ordinary fountain syringe and the rectal catheter connected with it. 

Immunity from Diphtheria. — An injection of 500 to 2000 antitoxin 
units will confer immunity from diphtheria in a case of scarlet fever. 

Diphtheria. — If diphtheria complicates scarlet fever, then the usual 
treatment of diphtheria should be instituted (see chapter on "Diphtheria"). 

At the Eiverside Hospital every case of scarlet fever is injected with 
500 to 1000 diphtheria antitoxin units as a prophylactic measure. By this 
means Dr. Eichardson believes that we have reduced the complication of 
diphtheria in about 50 to 75 per cent, of all cases. 

Fever. — The use of tepid water as an antipyretic measure is the 
safest means of reducing fever without depressing the heart. Each 
fever should be studied by noting how much depression is caused by 
it — how the child stands the temperature. If the child appears bright and 
cheerful and there is little constitutional disturbance from high fever, then 
cool sponging or tepid packs may be ample; if, however, there is marked 
depression, then a warm bath may serve our purpose much better. When a 
bath is used, the child should be immersed in a tub of water having a tem- 
perature of 90° F., and after the patient is immersed add cold water or ice 
until the temperature of the water is reduced to 80° F. In all a bath should 
last about three minutes, not longer than five minutes. It is important to 
watch the pulse while the child is in the bath. The temperature should be 
taken before and about ten minutes after the bath to note the fever. We 
can then see what effect has been produced. Such baths may be repeated 
in three, four, or six hours, depending on the individual requirements. 

An ice-cap may be placed on the head after the bath. 
The treatment of fever is of the greatest importance. When there 
is stupor, drowsiness, and delirium, the tepid bath will be indicated. 
Cold packs and cold sponging are also valuable. Antipyrine, phenacetine, 
and quinine are extolled by some and condemned by others. When used 
they should always be combined with musk or camphor, or given with coffee 
to counteract the well-known cardiac depression caused by the antipyretics 
belonging to the coal-tar series. 

In the treatment of high temperature in scarlatina and infectious dis- 
eases, injections of sulpho-carbolate of soda, 10 grains to a pint of cool 



^ 






SCARLET FEVER. 673 

water (temperature, 70° F.), is one of the best means of reducing fever. 
These injections should be repeated every three or four hours. 

"High post-eruptive temperatures arc often and have hem repeatedly 
traceable to infelicities of ingestion and digestion, and arc more effectively 
relieved by prompl and sufficient enemas than by any other treatment 
These high post-eruptive temperatures repeatedly arising in the same in- 
dividual have been accompanied synchronously by sensible increase of sub- 
maxillary swelling and tenderness, followed by the quick abatement of these 
lymphatic swellings along with the reduction of temperature from cooling 
antiseptic enemas/' 



CHAPTER X. 

DUKE'S DISEASE 1 — (FOURTH DISEASE). 

This is a feebly contagious disease with very slight subjective 
symptoms, and characterized by a "maculo-papular rose-red rash, more 
pronounced on the cheeks, legs, and outer surface of the arms. The 
specific agent is unknown. The disease occurs in epidemics, and often fol- 
lows an outbreak of measles or rotheln. It is found to spread through 
families, and a number of cases have been observed at the same time in 
schools and kindergartens. It is undoubtedly carried by contagion, but 
it is not so contagious as the other exanthemata." 

Children between the ages of I- and 12 are mostly affected, although 
infants and adults may also be infected. The disease is seen in both sexes 
and occurs mostly in spring and summer. The period of incubation is 
from 6 to 1-1 days. 

Symptoms. — "The disease may be ushered in by a slight feeling of 
malaise, weakness, and sore throat, but in the majority of cases the first 
symptom noticed is the eruption. This is the most important and often 
the only symptom. It appears invariably on the external skin, and no 
constant changes on the mucous membranes have been observed. A diag- 
nostic feature of the disease is the character of the rash on the face, where 
it first makes its appearance. The cheeks are chiefly affected, and present 
a symmetrical rose-red efflorescence. The skin is hot to the touch, and is 
swollen, but it is not at all sensitive and does not itch. The color disap- 
pears on pressure, but quickly reappears. The whole appearance is sug- 
gestive of erysipelas. The eruption is confluent over the cheeks, and the 
edges are well defined, slightly raised, and distinct from the normal skin, 
but it may gradually fade on to normal skin. The area of confluent erup- 
tion is rather sharply limited in front by the nasolabial folds, and above by 
the temples. Laterally it extends to the angles of the jaws. The skin 
around the mouth appears pale in contrast to the livid hue of the cheeks. 
Discrete spots, varying in size from a pea to a hazel-nut, are often seen on 
the forehead and chin. The rash fades from the face after four or five days. 
About the second day the eruption makes its appearance on the body, where 
it is most marked on the outer surface of the arms and legs. The trunk 
is involved to a much less degree, and may be almost free, but in no case 
is the rash so intense as on the face and extremities. The eruption spreads 
toward the periphery, and the hands and feet are the last portions of the 



1 1 am indebted to Shaw's article published in the American Journal of the 
Medical Sciences, January, 1905, for many valuable points in this article. 

(674j 



DUKE'S DISEASE. 675 

body to be affected. On the extremities the exanthem is typical and char- 
acteristic. It is morbilliform in appearance, and not so deeply rose-red 
as on the face. The contour of the eruption presents frequently almost 
geographical outlines, and in many cases the appearance is suggestive of 
laccwork, especially as it begins to fade at the end of the disease. On the 
inner or flexor surface of the arms the eruption is not nearly so intense. 
It is apt to become confluent around the outer surface of the elbow. On 
the legs the eruption is similar to that on the arms, and it is always espe- 
cially well marked on the buttocks. The trunk remains comparatively free 
from eruption, although a number of discrete spots, sometimes crescentic in 
form, can be seen sparsely scattered over the chest and back. The rash is 
more macular than papular, and shows only a slight elevation, except on 
the face, where it is always raised. An evanescence is often observed which 
is perhaps peculiar to this disease. The rash will apparently disappear 
when some slight irritation of the skin, such as friction, exposure to cold, 
etc., will bring it out again in full bloom. The eruption is not followed by 
desquamation. It lasts from six to ten da3 r s, and does not leave any stains 
or markings such as are sometimes seen after measles. No haemorrhage 
results on pinching the skin as occurs in measles and scarlet fever. The 
lymphatic glands are not enlarged as a result or accompaniment of this 
disease. 

"The subjective symptoms are conspicuous by their absence. The 
tongue may be slightly coated, but it never presents the strawberry appear- 
ance and desquamation of scarlet fever. The conjunctivas are not con- 
gested, and there is no coryza or cough. The urine is normal/' 

The prognosis is excellent and no complication or sequelae have been 
observed. 

The treatment is symptomatic throughout. 

Bibliography. 

1. Tschamer: Jahrbuch f. Kinderheilkunde, 1886, Bd. xxix. 

2. Gumplowicz: Ibid., 1891, Bd. xxxii. 

3. Tobeitz: Archiv. f. Kinderkrankheiten, 1896, Bd. xxv. 

4. Eseherich: Transactions of the Eleventh International Medical Congress, 
Moscow, 1896. 

5. Schmidt: Wiener klinische Wochenschrift, 1899, No. 47. 

6. Strieker: Zeitschrift. f. practische Aerzte, 1899. 

7. Berberich: Inaugural Dissertation, Giessen, 1900. 

8. Feilchenfeld: Deutsche med. Wochenschrift, 1902, No. 33. 

9. Tripker: Kalender f. Frauen und Kinderarzte, Kruznaek, 1901. 

10. Plachte: Berliner klinische Wochenschrift, 1904, No. 9. 

11. Heimann: Jahrbuch f. Kinderheilkunde, February, 1900. 

12. Eseherich: Ibid., 1904, No. 22. 

13. Dukes: London Lancet, July 14, 1900. 

14. Ker: The Practitioner, February, 1902. 

15. Pospischill: Wiener klinische Wochenschrift, 1904, Nos. 7, 25. 

16. Shaw: American Journal of the Medical Sciences, January, 1905. 



CHAPTEE XI. 
VARICELLA (CHICKEN-POX). 

Varicella is a specific infectious disease of an acute character. The 
eruption consists of vesicles which appear in successive crops. The attack 
lasts in all from four to fourteen days. After one attack the child is usually 
immune during the rest of its life. 

Etiology. — This disease is seen only in young children; the older the 
child the less liable it is to have chicken-pox. Nurslings are frequently 
afflicted. 

Hutchinson states that in his experience adults are almost absolutely 
immune from this disease. In my own practice the majority of cases seen 
by me have been in children between the second and tenth years of age. 

Pathology. — The pathological lesions are confined wholly to the epi- 
dermis. "The vesicles contain granular fibrin, a moderate cellular exudate, 
cellular debris, and serum; this differs markedly from the exudate in variola, 
which is usually very rich in cells, especially plasma cells. The pock in 
varicella is shallow, rarely involving the papillae of the cutis, and as its con- 
tents are absorbed, the superficial covering is cast off in the form of a 
brownish scab, sometimes with marked pigmentation, but no resulting scar. 
The occurrence of a scar following the varicella lesion is occasionally seen/' 

Diagnosis. — The distinguishing features of varicella are: "(a) Its 
mild prodromal symptoms, which may be wholly absent. ( b) The appear- 
ance of the eruption on the trunk, where it is usually more abundant than 
on the face and hands, (c) The multiform character of the eruption, its 
superficial position, comparable to drops of water sprinkled over the skin, 
and its appearance on the same region in successive crops, (d) Its mild 
constitutional symptoms and short duration; the disease usually terminates 
within from five to fourteen days, (e) Varicella is mildly infectious and 
always gives rise to a like disease." 

A nursing infant, about five months old, refused the breast, and seemed to 
show a general malaise. The infant had previously enjoyed good health. The 
nursing was regularly carried out and the bowels were normal. The temperature 
was 100° F. There was no cough. On the second day of this malaise several 
vesicles appeared on the abdomen and back. Later, some vesicles appeared on the 
buttocks, thighs, and in the roof of the mouth. There was no constitutional dis- 
turbance and on the third day of illness the infant again nursed as usual. Several 
successive crops appeared, and each eruption remained about three days. Local treat- 
ment consisted in dusting the parts with cornstarch. Bathing was prohibited and 
small doses of calomel were given. No complications followed. 

(676) 



VARICELLA. 



677 



Differential Diagnosis. — This disease may be confounded with variola, 
as some mild rases o\' variola resemble chicken-pox. "The superficial strata 
of the epidermis are principally involved, and a serous exudate, which is 
frequently the first symptom of the disease, occurs at this point, resulting 
in a transparent, thin-walled vesicle, while in variola the shot-like, deep- 
seated induration and subsequent vesicular formation are sufficiently dis- 
tinctive to warrant a differential diagnosis. The lesions in varicella, as a 
consequence, are easily destroyed, and when seen present a transparent, 
beady appearance, some of which, having ruptured, leave excoriated areas; 
whereas in variola it is impossible to rupture the lesions so as to evacuate 
the entire contents without numerous punctures or by totally destroying the 
diseased area." 



Hate 


1 


2 


3 


4 


5 


6 


7 


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100' 

99° 


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Fig. 211. — Temperature Curve in Varicella. (Original.) 

In variola we have more uniformity of development : first papules fol- 
lowed by pustules and ending in desiccation, leaving black crusts. In 
chicken-pox we find a varying of lesions at the same time, so that we may 
have macules, vesicles, and pustules at one and the same time. In variola 
the eruption is thickly seen on the face and hands, the exposed portions of 
the body. In chicken-pox the eruption is seen on the abdomen and back; 
the parts protected by clothing are usually first covered. When called to 
doubtful cases the following points are worth noting: — 

V mbilication is seen in smallpox; it is absent in chicken-pox. "The 
length of time since vaccination, and whether or not the patient has ever 
had chicken-pox. Smallpox is extremely seldom encountered within three 
or four years after vaccination, while after that time the number of cases 
of varioloid or abortive smallpox steadily increases. Chicken-pox, like 
smallpox, occurs but once in the same individual. Prodromal symptoms 



678 THE INFECTIOUS DISEASES. 

are always present for several days, usually three, in variola; absent or of 
a few hours' duration in varicella. 

"The temperature often renders valuable aid in differentiating between 
the two diseases. In variola it rises rapidly, and even in mild or abortive 
cases usually reaches 103° to 104° F., when, on the appearance of the rash, 
a crisis takes place and it falls to the normal within a few hours, where it 
may remain throughout the remainder of the disease. Varicella, on the 
contrary, is seldom ushered in with fever, but the temperature usually rises 
one or more degrees as the eruption develops. When the case is seen for 
the first time after the eruption has appeared and, as often occurs, no 
definite history can be obtained, other symptoms must be relied upon." 

Varicella may also resemble impetigo. Impetigo is first seen on the 
face, especially about the mouth and nose. It is also seen on the hands. 
In studying the regional appearance of the eruption one can readily see 
the transmission and inoculation from face to hands and vice versa. This 
condition is never met with in chicken-pox. Impetigo may last weeks and 
months. Chicken-pox rarely exists more than two weeks. Impetigo is 
contagious and not infectious. Chicken-pox has been successfully inocu- 
lated. 

Prognosis. — The prognosis is invariably good. I have never heard of 
a fatal case of chicken-pox. Complications should, however, be guarded 
against and not invited by carelessness. 

Treatment. — A child suffering with chicken-pox should be put to bed 
and strictly isolated. Healthy children should not come in contact with a 
case of chicken-pox for at least two weeks. 

The diet should be liquid, and feeding should be given at regular 
intervals. The bowels should be loose, and if necessary stimulated by the 
aid of a laxative. 

For the eruption flannels and woolens should be avoided, and a cool, 
loosely fitting linen or muslin shirt or gown should be worn. It is safe to 
prohibit the daily bath until the eruption has disappeared. I prefer to 
dust the skin with some bland dusting powder such as talcum, corn starch, 
or rice powder several times a day. Iron and tonics may be given later if 
required. Locally, a paste made by mixing bicarbonate of soda with cold 
water and applied to the chicken-pox is cooling. 

Baby B., five months old, was attended by me in January, 1905. The infant 
had a severe form of varicella with gastric disturbances, such as vomiting and 
diarrhoea. On the sixth day after the appearance of the chicken-pox the infant 
scratched its arm. On the following day there was a temperature of 102° and a 
diffuse swelling surrounded the upper arm. There was marked tenderness and pain 
on the slightest motion. The swelling increased. The arm became reddened and a 



^m 



YARKLLLA. 



679 

The case 



diffuse erysipelas was diagnosed. The temperature increased to 105Vio°. 
was then Been by l>r. A. Jacob] in consultation. 

Treatment. — Loral treatment consisting of evaporating cooling lotions; lead 
and opium wash and bichloride were used without any marked benefit. Credo 






1 


DATES OF OBSERVATIONS 


Ja 


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H 


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13 


1*h 


AT 


16 


Cent. 


Fakr. 


AM>M 


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Fig. 2 1 2. — Erysipelas Following Varicella. Locally, pure alcohol, 
in which 1 / aooo bichloride mercury w T as dissolved, was applied on the ery- 
sipelatous surface continually. Case recovered. (Original.) 

ointment was rubbed into the axillary glands several times a day. An injection of 
10 cubic centimeters of antistreptococcus serum (Aronson) seemed to have very 
good effect. The cooling lotions were continued, but within tw^enty-four hours after 
the serum injection the temperature came down by lysis and after four days the 
temperature was normal. The case recovered. 



CHAPTEE XII. 

VARIOLA (SMALLPOX). 

This acute infectious and contagious disease is frequently seen in un- 
vaccinated children. It is rarely met with in children that have been prop- 
erly vaccinated. I have seen smallpox in very young infants and children 
that were unvaccinated during my service at the Riverside Hospital in the 
summer of 1902. 




Fig. 213. — Fatal Smallpox in an Unvaccinated Four-weeks-old Infant. 
Seventh day of eruption. (Kindness of Dr. J. F. Schamberg. ) 

Etiology. — The etiological factor, most likely a specific micro-organ- 
ism, has not yet been found. 

Among unvaccinated children between 1 and 10 years of age, some 
authors state that 58 per cent. die. During the Sheffield epidemic, of 
2892 unvaccinated children under 10 years of age living in infected 



Table No. 91. — Showing Number of Cases, and Percentage of Mortality (AllbuWs System) 



Under 5 years 
5 to 9 years . 
10 to 14 years 



Totals 



(680) 



Unvaccinated. 



Cases. 



1131 
952 

607 



2690 



Deaths. 



647 
385 
155 



1187 



Mortality 
Per cent. 



57.2 
40.4 
25.5 



41.3 



385 
1468 
3080 



4933 



Vaccinated. 



Deaths. 



30 
59 
90 



179 



Mortality 
Per cent. 



7.8 
4.0 
2.9 



4.9 



VARIOLA. 



681 






houses, 1.$ per cent, were attacked. During the Warrington epidemic 54.5 
per cent, of unyaccinated children under LO years of age were attacked. 

It is a curious fact that the resistance of children is less than that of 
adults. Nursing infants frequently have mouth, nose, and throat com- 
plications, which seriously interfere with their feeding, causing death. 

There are three types of variola: — 

Table No. 92. 



1. Natural 



Discrete 
\ Confluent 

Semi-confluent 



Discrete when the eruption is scattered 



f Confluent when the eruption is thick and 
\ flows together. 

f Semi-confluent when the eruption is discrete 
\ in some parts and confluent in others. 



f Purpuric 
2. Hsemorrhagic -j Hemorrhagic 
[_ Exudative 

{Anomalous 
Corymbose 



3. Modified. 



Corymbose when the eruption forms groups 
or clusters on various i arts of the body. 



The mode of infection is most probably a micro-organism which exists 
either in the vesicles, pustules, or crusts. It may be carried in the air so 
that infection may take place at some distance from the body. Some au- 
thors believe that the blood of smallpox patients contains the poison. Small- 
pox can be transmitted directly from person to person. It can also be trans- 
mitted from bedding or clothing worn by an infected person. Entering a 
room during the pustular and desquamative stages is sufficient to commu- 
nicate the disease. 

Symptoms. — In young children the disease is usually ushered in with 
convulsions. The pulse-rate ranges between 130 and 160. The respira- 
tion is labored and increased in frequency. 

Curschmann believes that these symptoms are clue "to an irritation of 
the respiratory centers. 

The temperature rises rapidly and continuously without the morning 
remission. Beginning with 102° or 103° F. on the first day of illness, the 
temperature soon reaches 105° F. (40.5° C.) until the eruption appears. 

With the first appearance of the eruption, the temperature frequently 
drops to normal. This symptom of fever occurs in no other exanthematous 
eruption. 

The Eruption. — "Reddish specks or dots developed into papules re- 
sembling flea-bites appear about the second day. After the papules have 



682 



THE INFECTIOUS DISEASES. 



attained the size of a small pea their summits gradually assume a trans- 
lucent glazed appearance which indicates the formation of a vesicle. As 
this enlarges a central depression or umbilication takes place which is 
looked upon as characteristic of the smallpox lesion. If punctured a small 
amount of mucilaginous serum exudes. The eruption is not confined to 
the skin, but is met with in the mucous membrane on the mouth, throat, 
and nose. 



Bate 


2 


3 


4 


5 


6 


7 


8 9 


10 


11 


12 




f 

105° 


M 


EP 


iflET 


AEf 


«E 


M 


E 


MEP 


t^lEMJE 


M 


E 


M 


E 


M 


E 


M 


E 


















— 4— 




































































i 


































i 


































• r 






















A 


































\ 




































J \ 




































f \ 
































103° 
102° 
101° 
100' 
99° 

98° 




/ 




































r 


































) 




































/ 


| 




































I 




































1 










































































L 




































\ 




































y 




































\ 




































\ 








































































V 


/ \ 


































\ 








































\ 




































\ 


A 


































V 


\ 


h~ 




































i 




































Ca. 




































V' \ 






































































L 




A 
































ii X 




r^ 
































\ 






\, 
































"3 




V 




^, 




























V 














































V 































































































































































































Fig. 214 —Temperature Curve in Variola. (Original.) 



Stage of Suppuration. — On the sixth day of the eruption there is a 
decided yellowish tint, due to the presence of pus cells or polymorphonuclear 
leucocytes resembling cream. The face usually presents an erysipelatous 
redness. 

Stage of Decline.— About the twelfth day of the eruption there is a 
spontaneous rupture of the pustules. After the contents are thus evacu- 
ated, or by absorption, we see evidences of desiccation. The pustular con- 
tents dry up and the pustule dies, leaving a blackish crust. These blackish 
or brownish crusts appear first where the eruption took place. We there- 
fore first note this condition on the arms, palms, and soles. The crusts 
separate from the body between the sixteenth and twenty-first days. 

Desquamation of a furfuraceous character takes place, lasting from 



VARIOLA 68 3 

one to two weeks. After this condition has disappeared the patient may 
be regarded as cured. 

Differential Diagnosis. — Corlett describes the great resemblance of 
smallpox to typhoid fever in its early stages, in a case seen by him. A 
strong Widal reaction was found, besides a bronchitis. 

Measles frequently resembles smallpox. Catarrhal symptoms always 
present in measles are absent in smallpox. The lesions in measles are 



B ^#009^^^ 




' dl ( 




ra-VjM&M ML 








fc&&i^5l Mlf^^K^iL*-^^ 




* *v Iffll 



Fig. 215.— Smallpox in a Child that was Vaccinated During the 
Incubation Period. Vaccination performed five days before the appearance 
of the variolous eruption. Little or no modification. (Kindness of Dr. 
J. F. Schamberg.) 

flat, soft, and velvety to the touch. The papules of smallpox are small 
and feel like shot imbedded in the skin. 

Scarlet fever sometimes resembles variola of a mild form. The 
premonitory symptoms of variola are very severe, and last two or three 
days, whereas those of scarlet fever are mild, last a few hours, and not in- 
frequently are entirely overlooked. The rash in scarlet fever appears on 
the upper part of the body, chest, cheeks, and neck. In variola a scar- 
latinal form of eruption is seen on the lower part of the abdomen and on 
the inner surface of the thighs. It is bright and fiery red in scarlet fever 
and dull red in variola. The conspicuous papilla? or strawberry tongue is 
present in scarlet fever and absent in smallpox. 

Impetigo is frequently mistaken for smallpox. Corlett describes the 
presence of supposed impetigo in Ohio in 1898 which gave rise later on 






684 



THE INFECTIOUS DISEASES. 







Fig. 216. — Mild Discrete Smallpox in an Unvaccinated Girl. Note 
absence of lesions upon the trunk, (Kindness of Dr. J, F. Scham- 
berg.) 



VARIOLA 685 

to an epidemic oi smallpox. Thus it is apparent thai there is a great 
resemblance between impetigo and smallpox, and vice versa. 

Chicken-pox is frequently mistaken for smallpox. I have already out- 
lined the differentia] points in describing chicken-pox (see chapter on 
"Varicella''). 

Syphilis may sometimes be mistaken for variola. A study of the 
temperature and pulse and careful observation for several days will 
usually clear up the diagnosis. In variola the eruption assumes a pus- 
tular character on the palms and soles. 

The Prognosis and Course are always bad in unvaccinated children, es- 
pecially in the very young. In the vaccinated the prognosis is always good. 

A series of cases was seen by me, during the summer of 1902, in the 
smallpox wards of the Xorth Brothers' Island Hospital. Out of twelve 
children seen not one had been vaccinated. One child was infected by 
its mother. 

As a rule the course extends over three weeks, rarely lasting four weeks. 
Complications of the nose, mouth, and throat of a catarrhal nature are 
occasionally seen. The outcome of the cases seen by me was quite good 
in spite of the severe character of the disease. 

Complications. — Swelling of the mucous membrane, such as oedema of 
the glottis, bronchitis, and broncho-pneumonia, frequently complicates 
variola. The eruption plus secretion, when present in the throat, are the 
cause of great irritation, and give rise to a hacking cough. Suffocatory 
symptoms may follow oedema of the glottis. Otitis of a purulent nature 
is frequently seen. It is usually accompanied by severe neuralgic pains. 

Treatment. — The best sanitary surroundings, fresh air, and the short- 
est possible isolation are advisable. The local application of a solution of 
glycerine and carbolic acid will tend to relieve the itching, and to soften the 
crusts. 

The bowels should be kept thoroughly cleansed, and the patient made 
comfortable by a tepid pack if the temperature is high or if delirium is 
present. An ice-cap and cold colon flushing will render the patient more 
comfortable. If cardiac depression exists, stimulation with musk, cam- 
phor, or champagne is advisable. Regarding sanitary measures the New 
York Health Department requires the immediate removal of a case of this 
kind to the smallpox hospital. The disinfection and thorough fumiga- 
tion of everything which was in contact with the case must be remem- 
bered if we wish to prevent the spread of the disease. 

Varioloid (Modified Smallpox). 

The symptoms are milder, the papules less in number, and the gen- 
eral condition shows an infection of a lesser type than we see in variola. 



THE INFECTIOUS DISEASES. 

The febrile symptoms may be the same as we see in true smallpox. The 
attack is shorter. The severity of the symptoms depends on the length of 
time since the last vaccination took place. 

Vaccination. 

Jenner noticed that milkmaids in Gloucestershire, England, who 
were inoculated with cow-pox, became immune to smallpox. 

In IT 98 he published this discovery and gave the world the benefit of 
the protective value of vaccination against smallpox. 

The serum taken from a vesicle of a calf which has vaccinia or cow- 
pox contains protective properties when transported to living beings. When 
a child is inoculated this same immunity can be transferred. All infants 
over six months of age should be vaccinated. When smallpox exists in the 
locality, then infants of any age should be inoculated to avoid infection. 
The nursing infant is not exempt from smallpox, as I have seen several 
cases, in very young infants, in the wards of the Riverside Hospital. 
When infants are robust and in good health there can be no contraindica- 
tion to their being vaccinated. Regarding older children that have been 
vaccinated, it is safe to revaccinate once every five years. 

Symptoms. — From five to ten days after inoculation a red areola is seen 
around the wound. Inflammatory symptoms are marked. The neighbor- 
ing lymph glands are swollen. 

Constitutional symptoms such as fever, anorexia, general malaise, and 
thirst are noted. This condition lasts usually from two to three days, 
rarely longer, unless some complication follows. 

The complications are erysipelas and cellulitis. Abscesses are usually 
the result of carelessness or infection. This infection usually takes place 
at the time of inoculation or may result from dirt or scratching with dirty 
nails or other filthy habits. (Read article on •''Varicella/') 

Syphilis and tuberculosis are frequently mentioned as accidental in- 
fections, but I have never seen or heard of a bona fide case resulting from 
vaccination. 

Varieties of Vaccine. — (a) Humanized; (b) bovine. 

Humanized vaccine is rarely or never used. By using human virus 
the chance of conveying syphilis or other disease has been thought possi- 
ble. Therefore, the bovine virus has been given preference. 

Where to Inoculate. — Usually on the arm, although the leg is some- 
times preferred for females. 

Arm. — The upper third of the arm is the part usually chosen. 

Leg. — When preference is shown for vaccination on the leg in female 
infants, the lower anterior outer third of the leg should be chosen. 

Good vaccine virus will take on almost any part of the body. 



VACCINATION. 



G87 



Fig. 217 shows a case of vaccination which I reported in Pediatrics. The 

child was vaccinated on the arm and after scratching the same she carried some 
of the virus from the arm to the check, causing a successful vaccination. 

Method of Inoculation. — The parts to be inoculated should be cleaned 
with soap and water; also the operator's hands. After thorough drying 
of the parts with cotton, a sterile needle should be used for scarifica- 
tion. A small square should be scratched crosswise, but no blood should 
he drawn. 




Fig. 217. — Accidental Vaccination on the Cheek. Showing successful 
vesicles and pustules, marked inflammation and oedema of the lower eye- 
lid. Permanent scar. (Original.) 



No antiseptic should be used to clean the part to be vaccinated, other- 
wise we destroy the vaccine virus. 

Glycerinized Lymph. — When using capillary tubes, break off the ends 
and blow the virus on the scarified area. See that it is well rubbed into 
the scarified area and allowed to dry. When dry protect the part with a 
shield or a sterilized gauze dressing. 

Ivory Points. — When using ivory points the point is dipped into sterile 
water after it has scarified the area to be inoculated. The moistened serum 
should then be thoroughly rubbed in and allowed to dry. The parts are 
then to be protected against infection as already described. 

Welch and Schamberg, in a series of cases, 1 call particular attention 
to the great difference in the death-rate between the vaccinated and the 



Therapeutic Gazette, June 15, 1902. 



688 THE INFECTIOUS DISEASES. 

unvaccinated patients. Those who were vaccinated in infancy and showed 
good scars gave the remarkably low death-rate of 2.61 per cent, as against 
the high death-rate of 28.17 per cent, in the unvaccinated. There is no 
doubt that all those who showed either good or fair scars were successfully 
vaccinated in infancy. If we consider them together, therefore, the 
death-rate is -1.84 per cent. In making a comparison between the vacci- 
nated and unvaccinated cases, it is scarcely fair to include as vaccinated 
all the cases showing poor scars, as very many of them doubtless were 
never successfully vaccinated. 

Patients who had been vaccinated seven days, or less than seven days, 
before the appearance of the eruption of smallpox, gave a death-rate of 
35.71 per cent., while those who had been vaccinated for a longer period 
than seven days before the outbreak of the efflorescence, gave a death- 
rate of only 14.28 per cent. 

Vaccinia. 

This acute condition is characterized by an eruption following the 
inoculation of lymph. When lymph is taken from a seropurulent eruption 
on the teat or udder of a cow, it is called cow-pox. Some authors believe 
that vaccinia is a modified form of smallpox. 

Symptoms. — An eruption resembling measles or scarlet fever sometimes 
follows vaccination. It usually involves the arms, neck, and chest; in rare 
cases it involves the whole body. It most commonly occurs between the 
eighth and eleventh days after vaccination. The temperature is rarely 
above normal and there is no constitutional disturbance. There is no treat- 
ment excepting cleanliness. Internally, a mild laxative may be given. 



PLATE Will 




Vaccinia Following Vaccination. Xote a roseola extending over the left 
arm and leg. also the face and abdomen. There were 710 constitutional dis- 
turbances. The rash appeared hetween tin 1 seventh and eighth days after 
the vaccination. Tt lasted two days. (Original.) 



CHAPTEB XIII. 

TYPHOID FEVER. 

Typhoid fever is an acute infectious disease caused by the invasion of 
a specific micro-organism, known as Eberth's typhoid bacillus. 

Etiology. — Tvphoid is rarely seen in infants. It is most frequently 
seen in children over 5 years of age. In a series of 97 cases described by 
Henoch : — 

2 cases occurred during the 1st year 
21 cases between the 2d and 5th years 
59 cases between the 5th and 10th years 

Von Steffens in a series of 148 cases reports : — 

2 cases occurred during the 1st year 
28 cases between the 3d and 6th years 
34 cases between the 6th and 9th years 

I have seen typhoid fever in an infant 1 year old which was infected 
by its mother. 

Baginsky describes an epidemic of typhoid seen by him in Germany, 
in which 16 cases were under 10 years of age. 

Infected water and infected milk appear to have caused this disease 
more than any other factor. Baginsky mentions flies as an occasional 
source of infection. 

The Xew York Health Department, in a circular of information con- 
cerning the urine in typhoid fever, directs attention to the fact that "the 
typhoid bacilli are present in almost incredible numbers, estimated at many 
millions per cubic centimeter." 

These germs find a suitable culture medium for their propagation in 
the intestinal tract. They are very easily found in the faeces in the living 
state during the height of the disease. 

The entrance of the typhoid bacillus into the gastro-intestinal tract, 
whether it is in food, liquid or solid, is responsible for the disease. It is 
true that a receptive condition may exist. A child having had a series of 
gastro-intestinal attacks is more liable to an infection than one whose diges- 
tive tract is normal. Eickets and a general debilitated condition certainly 
favor the development of typhoid. 

Typhoid fever occurs most frequently in the fall of the year. I have 
seen more cases of typhoid in children during September and October than 
during the rest of the year. During the fall and winter of 1902 and 1903 
some of the worst cases of typhoid with haemorrhages occurred. 

(689) 



690 



THE INFECTIOUS DISEASES. 



Bacteriology. — The typhoid bacillus resembles the bacillus coli com- 
munis, and is found chiefly in the lymphoid tissue of the small intestines, 
especially in Peyer's patches, where it produces a specific inflammation. 
The bacillus is found not only within the intestines, but in the glands as 
well. Neuhaus found the bacillus by puncturing the roseolar eruption 
and examining the blood therein. It has also been found in laryngeal 



Table No. 93. — Deaths from Typhoid Fever in Children Under 15 Years of Age- 
Old City of New York. 










Years. 


l 
Year. 


2 
Years. 


3 
Years. 


4 
Years. 


Under 5 
Years. 


5 to 10 
Years. 


10 to 15 
Years. 


1890 


Males 
Females 


27 
27 


1 


2 
2 


1 


4 
1 


3 


8 
6 


9 

8 


10 
13 


1891 


Males 
Females 


34 
42 


1 
1 


3 

2 


1 
5 


5 
2 


3 
1 


13 
11 


12 
14 


9 

17 


1892 


Males 
Females 


37 
25 


1 
2 


4 

2 


2 


4 
1 


1 

1 


12 
6 


10 
14 


15 
5 


1893 


Males 
Females 


24 
19 


1 


2 

2 


2 


2 
1 


3 


7 
6 


12 

7 


5 
6 


1894 


Males 
Females 


25 

24 


2 
1 


1 
1 


1 

2 


1 


1 


5 
5 


9 
6 


11 

13 


1895 


Males 
Females 


24 

18 


2 


3 

1 




3 


3 


8 
4 


6 
6 


10 

8 


1896 


Males 
Females 


29 

27 


2 
2 




1 

2 


3 


3 
1 


9 
5 


11 
13 


9 
9 


1897 


Males 
Females 


17 
28 


2 


2 


2 

1 


2 

4 


1 


5 
9 


7 
9 


5 
10 


1898 


Males 
Females 


32 

17 




1 
1 


1 


2 
2 


1 
1 


5 

4 


9 

7 


18 
6 


1899 


Males 
Females 


13 

18 




1 


1 


1 


1 
1 


3 
2 


3 

8 


7 
8 


1900 


Males 
Females 


30 
19 


2 


2 
2 


2 
1 


1 

2 


2 
3 


9 

8 • 


11 
6 


10 
5 


1901 


Males 
Females 


25 

28 


1 


3 
1 


2 
1 


2 
2 


4 
4 


11 
9 


6 

4 


8 
15 




Total 


509 


21 


38 


28 


45 


38 


70 


201 


232 



typhoid ki:\ i:k. 



091 



ulcerations during typhoid. The bacillus was also round in the purulent 
meningitis accompanying typhoid, so thai we ran be reasonably certain 

that the bacillus abounds in almost every part of the body. The action 

of typhoid bacillus on the human system is 

toxic. Brieger isolated a poison from the 

typhoid bacillus, which is called the typho- 

toxin. 

Pathology. — The pathological findings 
consist in an inflammatory condition of the 
mesenteric glands: besides these the solitary 
and agminated glands of the ileum and colon 
not only show evidences of swelling, but 
when the disease progresses it frequently ter- 
minates in ulceration and necrosis. 

Occasionally the glands will show a 
softening and pus will develop. The spleen 
is usually very large and soft, and quite pal- 
pable. When the disease lasts several weeks 
and there are evidences of a distinct toxaemia, 
the poison will cause a marked degeneration 
of the kidneys and liver, also affecting the 
heart muscles, which, later, will be found 
very soft and flabby. 

Morse 1 reports several cases of fcetal and 
infantile typhoid. 

Fcetal and Infantile Typhoid. — In re- 
gard to foetal typhoid he says that the ty- 
phoid bacillus can transverse the abnormal, 
and possibly the normal placenta from 
mother to foetus. Other organisms may also 
pass in the same way. 

Infection of the foetus results. Because 
of the direct entrance of the bacilli into the 
circulation, intrauterine typhoid is from the 
first a general septicaemia. For this reason, 
and possibly also because the intestines are 
not functionating, the classical lesions of 
intrauterine typhoid are wanting. 

The foetus usually dies in utero or at birth as the result of the typhoid 
infection. 

It may be born alive but feeble and suffering from the infection. If 
so, death occurs in a few days without definite symptoms. 

1 Archives of Pediatrics for December, 1900. 




Fig. 218.— Typhoid Infantum 
in a 2- Year-Old Boy. (a) Soli- 
tary follicle; (b) small agmin- 
ated gland; (c) Peyer's patch. 
General medullary infiltration, 
no ulceration. Xatural size. 
(Langerhans.) 



692 THE INFECTIOUS DISEASES. 

It is possible that the foetus may pass through the infection in utero 
and be born alive and well. There is, however, no proof that this happens. 

Infection does not always occur. The pregnant woman does not neces- 
sarily transmit the disease to her child. 

As to infantile typhoid Morse concludes that except for the lessened 
exposure in the first year through food there seems no obvious reason why 
typhoid should be less frequent in infancy than in later life. Nevertheless, 
judging from the small number of cases reported, it is less frequent. It may 
really be less frequent, or only apparently so because the disease is not recog- 
nized, being mistaken for other conditions. Bacteriological examinations in 
large series of autopsies on infants and the use of the Widal serum test in 
large numbers of sick babies seem to offer the best means for determining 
both the frequency and the character of the disease at this age. 

The accuracy of the diagnosis in many of the earlier reported cases 
must be regarded as very doubtful, and hence no satisfactory conclusions 
can be drawn from them. Analysis of the more recent and certain cases 
seems to show that the symptoms of infantile typhoid are essentially the 
same as in adults, but that the course is shorter and the mortality greater. 
These conclusions may be inaccurate,- however, as it is possible that they 
are based on the severe cases alone, the milder cases having escaped notice. 
The pathological changes in the intestines are, as a rule, insignificant. The 
contrast between them and the severity of the general symptoms is striking. 
The probable explanation is that in the infant as in the foetus, but to a less 
degree, the disease is a general rather than a local infection. 

The serum reaction occurs in infantile as in adult typhoid. There are 
no data as to whether or not it occurs in foetal typhoid. 

Immunity. — The agglutinating power may or may not be present in 
the blood of infants born of a woman with typhoid. If present, it is trans- 
mitted from the mother to the child through the placenta. It is possible, 
however, that it may be formed in the child in response to toxins trans- 
mitted through the placenta. The agglutinating principle can pass through 
the normal placenta. Part of it, however, is arrested in the passage. 
Whether or not it is transmitted seems to depend on the strength of the 
agglutinating power in the maternal blood and the length of time during 
which the placenta is exposed to it. 

It may be transmitted to the nursling through the milk. It may appear 
in the infant's blood in less than twenty-four hours. It lasts but a few 
days after the cessation of nursing. It is always weaker in the milk than 
in the maternal blood and always weaker in the infant's blood than in the 
milk. This weakening of the agglutinating power is due to the obstruction 
to its passage in the mammary gland and in the nursling's digestive tract. 
The chief factor governing transmission is the intensity of the power in 
the maternal blood. A subordinate but important factor is some unknown 



. TYPHOID l"i:\ ER. 093 

condition in the digestive tract. If the power in the maternal blood is 
weak and the obstacles great it may not be transmitted. 

Symptoms.— The symptoms are usually very obscure in children. 
Vomiting and sometimes diarrhoea are the earliest symptoms. Jn other 

cases constipation may he an early symptom. The so-called pea-soup diar- 
rhoea seen in adults and older children is rarely met with in young infants. 
Convulsions frequently usher in an attack of typhoid fever. 

In older children, those able to complain will usually give subjective 
symptoms, which may aid materially in making the diagnosis. A constant 
headache, for example, will always show a severe form of infection, and 
may be the only symptom which will be constant. 

The period of incubation varies from five to fourteen days. We can 
safely say it is rare for the period of incubation to extend over three w^eeks. 

The Temperature. — The temperature is one of the main indications 
of typhoid. It rises at night and falls in the morning, the morning fall 
being less and the evening rise greater for the first week (step-laddder type) 
until the maximum is reached. The temperature shows fairly regular oscil- 
lations, morning fall and evening rise for about a week. It then returns 
to normal at the end of the third, sometimes at the end of the fourth or fifth 
week. The temperature drops by lysis, never by crisis. 

Secondary fever is rare in children. It is not unusual to find a mild 
form of typhoid terminating normally at the end of two weeks. 

During the second week of the disease when the temperature remains 
fairly constant, the diagnosis will be much easier, although a positive diag- 
nosis from the temperature alone should not be made. The temperature in 
a mild form of typhoid in an infant varies between 101° and 103° F. during 
the first week, or even the second week, of the disease. Severe cases may 
show a temperature of 105° F., or even higher, during the first week of 
the illness. The temperature may show r peculiar variations. We may have 
a sudden rise extending over a period of six weeks instead of three weeks. 
This prolonged pyrexia sometimes denotes complications. If the tempera- 
ture has ranged between 103°, 104°, or 105° F., and suddenly drops to 
normal or subnormal, then we must suspect either an internal haemorrhage 
or look for a perforation. Sudden variations in the temperature, as a very 
sudden rise or fall, must always be looked upon with suspicion. There is 
no crisis in typhoid as there is in pneumonia. 

The Pulse. — The pulse is usually increased in frequency and ranges 
between 130 and 160 per minute. The force and rhythm are good unless 
some complication arises. The pulse is usually small and compressible, and 
there is very low tension in fatal forms of the disease. 

The Tongue. — The tongue is coated with a whitish, more rarely a 
brownish, fur. This coating extends down the center, although the whole 



694 



THE INFECTIOUS DISEASES. 



tongue may be covered. The mouth appears very dry, and the patient 
sometimes complains of intense thirst. 

The abdomen is usually distended with gas and there is marked tym- 
panites on percussion. Gurgling and tenderness on palpation in the ileo- 
cecal region is not to be looked upon as an important symptom. 

The Spleen. — The spleen cannot be relied upon as a diagnostic aid in 
children. While it may be enlarged in some instances, we frequently find 
that it is not palpable in many cases of severe typhoid. 

Coughs and Bronchial Catarrh. — One of the earliest symptoms in ty- 
phoid is bronchitis. In the beginning when we have but cough and fever 
the diagnosis will be quite difficult. Typhoid frequently simulates pneu- 

The Nervous System. — In profound tox- 
icity the nervous symptoms present will be 
muttering, delirium, and a semi-comatose 
condition. Not infrequently rigidity of the 
muscles of the neck is present, so that the 
differential diagnosis from meningitis will 
be difficult. The nervous symptoms fre- 
quently resemble those seen in tubercular 
meningitis. Acute tuberculosis may some- 
times resemble typhoid. 

Extreme Emaciation. — Children fre- 
quently show emaciation during typhoid for 
the following reasons : — 

1. The constant fever. 

2. The low vitality owing to mal- 
nutrition. 

3. The system being constantly drained when diarrhoea exists. 

Diagnosis. — In every case of fever in which a diagnosis cannot be made, 
a drop of blood should be examined, for the presence of the Widal reaction. 
This reaction is always a trustworthy evidence of the presence of typhoid, 
and a negative reaction later than the tenth day is strong but not absolutely 
convincing evidence of the absence of typhoid. The test is of greater 
value in the case of an infant than an adult, as we can exclude the occurrence 
of a previous attack. Some writers state that the reaction is seen earlier 
in children than in adults. 

It should not, however, be the only means of making a diagnosis. It 
is well known that this reaction will occur months and sometimes years 
after the patient has recovered from typhoid, hence great caution should be 
used in relying on this diagnostic measure exclusively. 

Widal Test for the Diagnosis of Typhoid Fever. 1 — The investigations 




c 

Fig. 
Reaction 



219.— Stages in Widal 
(After Robin. ) 



x This method is described by the New York Health Department. 



TYPHOID FEVER. 695 

of Griiber, Widal. and others, published in L896 3 showed that the blood 
of persons, Buffering from or haying recently had typhoid lever, contains, 
aa a rule, alter the fifth day of the disease, Bubstances which, when added 
to a broth culture of the typhoid bacilli, arrest the characteristic move- 
ments of these organisms and cause them to become clumped together in 
mass 

The results of a very large number of examinations made here in New 
York and elsewhere show, that if the blood contains agglutinating sub- 
stances in sufficient amount to cause a prompt and marked reaction, when 
one part of serum or blood solution is added to 10 parts of a broth culture 
of the typhoid bacillus, the presence of a previous or existing typhoid in- 
fection may be considered as extremely probable, and that if these sub- 
stances are present in such an amount as promptly to produce the reaction, 
when 1 part of serum or dried blood solution is added to 20 parts of the 
culture, the presence of a previous or existing typhoid infection may, for 
diagnostic purposes, be practically considered as established. 

In estimating the diagnostic value of a negative result from this test, 
we must remember that the reaction is rarely, if ever, present until at least 
four days after the appearance of symptoms; that it is occasionally absent 
in cases of typhoid fever until the third or fourth week, or even until con- 
valescence is established; that when developed it may disappear after a 
few days, and that no definite relation between the severity of the disease 
and the degree and time of development of the substances causing the 
reaction has been established. For these reasons a single negative result 
in any suspected case only renders doubtful the existence of typhoid fever. 
In those cases in which the reaction is absent after the ninth day, it may 
be reasonably assumed that the large majority will not prove to be typhoid 
fever, and the absence of the reaction in all of several different cases of a 
suspected group, or after repeated examinations in any single case, affords 
evidence of very decided value in excluding the diagnosis of typhoid fever. 

Directions for Preparing Specimens of Blood. — The skin covering the 
tip of the finger is thoroughly cleansed and then pricked with a clean 
needle deeply enough to cause several drops of blood to exude. Two large 
drops are then placed on the glass slide, one near either end, and allowed 
to dry without being spread out on the surface of the slide. After they 
have dried, the slide is placed in the holder and returned in the addressed 
envelope to a culture station, or mailed to the laboratory. 

The diazo reaction should be looked upon as a valuable aid in making 
the diagnosis. It is described in detail in the chapter on "Urine," page 923. 

The Eruption. — The eruption consists of lenticular-shaped, rose-col- 
ored spots. They are small and slightly elevated. These rose-colored spots 
appear at the beginning of the second week. The eruption lasts about ten 
days, although the spots last from two to three days and are succeeded by 



696 



THE INFECTIOUS DISEASES. 



a new crop. They are seen on the thorax and abdomen, although at times 
over the whole body. 

Leucopoenia if present strongly supports the diagnosis of typhoid. In 
the International Clinics 1909, I report a series of cases in which the white 
blood cells ranged between 4000-6000 at the beginning of the disease. 

Differential Diagnosis. — Malaria frequently resembles typhoid. A dif- 







Fig. 220.— Typhoid Fever.— Severe haemorrhages. Fatal result. (Original.) 



ferential diagnosis can easily be made by an examination of a drop of blood 
for the presence of plasmodia. 

The administration of quinine is a diagnostic test of practical im- 
portance. An irregular or intermittent fever ivhich yields promptly to 
quinine is certainly not typhoid. In malaria, the temperature will be found 
to touch normal at some time in the twenty-four hours. 

Cholera Infantum. — Many cases of supposed cholera infantum fre- 
quently prove to be typhoid fever. I have seen many cases in midsummer 



TYPHOID FEVER. (397 

with a temperature of 102° F., having roseola, with vomiting and diar- 
rhoea. In Buch cases the diagnosis depends on the presence of the Widal 
reaction. 

When diarrhceal symptoms and fever are present in the early stages 
of typhoid lever it is extremely difficult to make a diagnosis. This applies 
especially to the first week of the disease hefore a Widal reaction can be 
made. I have invariably examined the urine for the presence of indican 
(see page 925). When the symptoms are due to intestinal autointoxication 
or fermentative conditions in the intestine, then a positive indican reaction 
is present. If the diazo-reaction is absent and indican present, we can 
exclude typhoid fever. 

Internal Haemorrhages. — Holt reports a series of 946 collected cases 
in which haemorrhage occurred in 30 cases, about 3 per cent. The ma- 
jority of these cases were over 10 years of age. I have frequently seen 
haemorrhages in children between 5 and 10 years ; never under 5 years. 

Case I. — A case of typhoid in a boy 16 years old, seen in consultation with Dr. 
Rayewsky, had a series of haemorrhages which ended fatally. The origin of this case 
was supposed to be an infection from eating raw oysters. The boy was a telegraph 
messenger and ate some oysters in the street, after which he showed signs of fever, 
and intestinal symptoms. No other etiological factor was ascertained. The boy 
was in good health and suddenly became ill after easing this meal of oysters. Symp- 
toms of gastric fever, with diarrhoea; temperature of 101° to 103° F. gradually 
appeared. The symptoms increased from day to day until delirium and general coma 
were present. The fever was difficult to control in spite of cold tub bathing. The 
boy weakened from constant pyrexia — appeared to convalesce — when a severe haemor- 
rhage occurred. An ice-bag was laid over the abdomen, and opium given internally. 
The colon was flushed with alum and water. Xothing seemed to control the bleeding. 

Case II. — A girl, 10 years old, was seen in consultation with Dr. H. Wein- 
stein. She had been sick about three weeks when seen by me. She was apparently 
convalescing when she had a haemorrhage of a very alarming nature. The doctor 
told me the child lost more than one pint of blood. The pulse was about 130 and 
very feeble in character. The child was deathly pale and seemed to be in collapse. 
Whisky and strychnine were ordered as restoratives. The child complained of chills 
and was thoroughly wrapped in warm blankets and hot-water bottles were applied 
to her feet. A teaspoonful of powered alum added to a pint of cold water was in- 
jected into the rectum and colon. Paregoric in 15 drop doses was ordered every hour. 
The nurse was instructed to watch the pupils and the pulse and to discontinue the 
drug as soon as the systemic effect of the paregoric was manifested. Ice-cream was 
ordered internally and small pellets of cracked ice. The child recovered after 
careful dietetic and restorative treatment. 

Intestinal Perforation. — Intestinal perforation is very rare. It is met 
with in about 1 per cent, of all cases. A sudden fall in the temperature 
with collapse, rarely vomiting, followed by tympanites, are symptoms indi- 
cating perforation. 

Laparotomy When Perforation Occurs. — The skill of the surgeon will 
frequently save life when haemorrhages occur. In a case of typhoid which 



698 THE INFECTIOUS DISEASES. 

progresses favorably during the third and fourth week, a sudden collapse 
should be an indication for an immediate operation. I have seen death 
follow a case of this kind. These cases are usually hopeless and our only 
chance consists in resorting to an immediate operation. 

Complications. — Aphasia is occasionally met with. Morse reported 21 
cases. Insanity is rarely met with as a sequel to typhoid. Chorea is fre- 
quently seen. I have met with a case having a severe form of choreiform 
movements which lasted more than a year, following the attack of typhoid. 

Otitis media is frequently met with in children. It is very important 
to watch the ears during an attack of typhoid. 

Less frequent complications are gangrenous inflammation of the mouth 
or genitals, pericarditis, endocarditis, peritonitis, pyaemia, abscesses, and 
furuncles. Abscess of the liver has been reported by Bokai. Pulmonary 
tuberculosis has been known to follow typhoid. 

Prognosis and Course. — The prognosis is more favorable in children 
than in adults. Tympanites, if accompanied by vomiting, is a bad sign. 
When there is general depression and nervous symptoms then the prog- 
nosis is bad. Singultus is usually a bad sign. Bleeding should always be 
looked upon, especially if repeated, as a bad sign. The strength 
of the child, its assimilation pf food, and the condition of the heart should 
be the means of arriving at the proper prognosis. Complications should 
always be regarded as a serious matter. The prognosis is grave if the 
child has passed through a typhoid and is in an exhausted condition, and 
unable to cope with a new complication. Baginsky states that in a series 
of 68 cases treated by him in the hospital, 6 died, a mortality of 8.8 per 
cent. 

In children typhoid may terminate in two weeks. It may extend 
over three weeks or even four weeks. Mild cases of typhoid resem- 
ble an attack of acute gastric fever. Cases are occasionally seen in which 
the disease terminates abruptly within ten days. As a rule older children 
show the adult type of fever and the disease runs its course of three, four, 
or six weeks. Infantile typhoid may show severe gastric symptoms, such 
as vomiting, and very little diarrhoea. The course, therefore, is peculiar to 
infants and entirely different from that seen in the older child. 

The following case was seen by me some time ago. A woman, 35 years of age, 
was taken ill with typhoid fever of a very severe type. She nursed her infant during 
the first week of her fever. The infant was then 1 year old. The physician ordered 
the infant weaned. About one week later the infant had fever, vomiting, and diar- 
rhoea. An examination of the blood gave a positive Widal reaction. The infant 
recovered in about fifteen days. The mother died of haemorrhages during the third 
week of her illness. 

Treatment. — The specific nature of the disease due to the infection 
of a specific germ, has caused investigators to seek a typhoid antitoxin. As 
yet no definite progress has been made in this direction, although inves- 



TYPHOID FEVER. 699 

tigatora have from time to time announced the discovery of a healing Berum. 1 
In the absence of a specific serum we must confine ourselves to the treat- 
ment of indications. In the beginning a good dose of calomel, l / a to 1 
grain, repeated several times a day, is indicated. 

Fi Vi r Treatment. — The hest antipyretic is the cold bath and cold pack. 
The hath must be properly given to be effective. A large bath-tub should 
be procured, large enough to hold the child at full length. This should 
be half-filled with water at a temperature of 90° F. Cold water or, in 
summer, ice should be added until the temperature is gradually reduced 
to 7 0° F. This is an agreeable method, as we avoid the sudden shock so 
dreaded by children when suddenly immersed in cold water. The dura- 
tion of the bath should be from three to five minutes. 

The temperature of the child should be taken before and after the 
bath. The child's body should be rubbed continuously while in the bath 
so as to stimulate the circulation, especially so when the water is cool. If 
the child's pulse is feeble, administer a stimulant such as hot coffee or 
whisky before the bath. "Watch the pulse carefully, and if the slightest 
sign of weakness is noted, remove the child immediately from the bath 
and place in bed with hot-water bottles to its feet. The bath should be 
repeated every three or four hours or oftener, if the temperature requires 
it. If the temperature is not modified lower the temperature of the bath. 

Antipyretic drugs, such as napthaline, benzoate of soda, quinine, anti- 
pyrin, antifebrin, phenacetin, and lactophenin, are useless in combating 
fever when compared to cold baths and cold packs. All antipyretic drugs 
of the coal-tar series are such cardiac depressants that they should never 
be prescribed without combining them with camphor or musk. Of all anti- 
pyretic drugs I prefer phenacetin. One of the best antipyretic measures is 
the injection of several pints of cold saline solution through a catheter into 
the colon. Too much hydrostatic pressure should not be used. The irri- 
gator should be held about one foot over the child's body ; the temperature 
of the water should be between 60° and 70° F. Flushing the colon with 
cool saline solution may be repeated every three or four hours if a good 
effect is apparent. When great exhaustion and a weak pulse exist, then 
1 / 2 teaspoonful or a teaspoonful of alcohol may be added to the irrigation. 
The main point to remember in the treatment is to support the child so 
that the strength will be maintained and the heart's action not im- 
paired. With this object in view nothing is better than restoring vitality 
by the aid of concentrated food. When there is great exhaustion the admin- 
istration of a normal salt solution per rectum, or its use by hypodermoclysis, 2 
should be remembered. One or two pints of saline solution administered 



1 Einhorn, of New York, has reported beneficial results from the use of anti- 
typhoid serum. 

2 This is illustrated in detail in the chapter on "Scarlet Fever Treatment." 



700 THE INFECTIOUS DISEASES. 

per rectum, with the hips elevated, is frequently the means of stimulating 
diuresis, thus eliminating the poisons of the toxins through the kidneys. 
Great care is required in giving the saline in the form of hypodermoclysis. 
The strictest asepsis should be maintained. A large aspirating needle 
attached to a fountain syringe (Fig. 208) is well adapted in an emergency. 
These saline injections may be repeated every six or twelve hours if required. 

Hygienic Measures. — Owing to the infectious nature of the discharges 
passing from a typhoid patient, the prime requisite is the thorough disin- 
fection of all stools and urine. If there is cough or sputum, the same must 
also be thoroughly disinfected. In fact all discharges should be received 
in a vessel containing a strong solution of javelle water (chlorinated lime) 
or a 5 per cent, carbolic solution. A strong solution of copperas should be 
thrown into the toilet from time to time while a typhoid patient is in the 
house. All bed linen, handkerchiefs, and dishes coming in contact with 
the patient should be soaked in a bichloride solution for at least one-half 
hour before being washed. Sunlight is of the greatest importance in a 
room having a typhoid patient. We can do more disinfection with sunlight 
and fresh air than we can with medication. 

The Food. — All food must be liquid ; no solid food should be allowed. 
In the beginning whey, strained soups, and broths should be ordered ; later 
strained gruels, cocoa, acorn cocoa, and chocolate may be given at intervals 
of two or three hours. In some cases albumin water, made by beating the 
raw whites of two eggs with sugar and water, is useful. I frequently give 
the whites of six eggs per day. Milk, buttermilk, kumyss, whey, or 
junket may be given, alternating with soups and broths. When stimulation 
is required the yolk of egg can be combined with sherry or Tokay wine. 
When drugs are given it is best to combine them with soups or broths. 
When severe dyspeptic symptoms exist, predigested milk, peptonized with 
the aid of pancreatin and soda, must not be forgotten. When milk idio- 
syncrasies exist, then the yolk of a raw egg added to barley water, rice 
water, or almond milk (made by blanching almonds with hot water) can be 
substituted for milk. When thirst exists, unfermented grape juice or 
water acidulated with dilute phosphoric acid- or dilute hydrochloric acid 
is very grateful. Ten drops of either dilute acid can be added to a 
tumblerful of sweetened water, and this given whenever the child is 
thirsty. These acids have a very good effect on febrile affections, and 
are especially indicated when diarrhoea exists. 

Feeding in Convalescence. — The great danger of haemorrhage should 
always be borne in mind ; hence it is advisable to abstain from giving solid 
food for several weeks after convalescence is thoroughly established. Soups 
thickened with sago, farina or barley, and pea and lentil soups can be given. 
The yolk of a raw egg can be added to the soup. Milk may be thickened 
with zwieback. The main diet should be milk and cocoa or chocolate. 



TYPHOID FEVER. 701 

Somatose may be added to milk or soup. Plasmon is also beneficial. 
Bovinine, liquid peptonoids, panopeptone, eucasin, or tropon, in teaspoouful 
doses added to milk, are very valuable during the convalescent period. 
Valentine's meat juice given in milk or soup is nutritious, or Mosquera's 
liquid beef (made by Parke, Davis & Co.) can be added to each soup or 
milk-feeding. 

Drug Treatment — If cerebral symptoms exist, then an ice-bag should 
be applied to the head. When there is severe restlessness and insomnia, 
with twitchings of the muscles, then injections of 3 to 5 grains of chloral 
hydrate should be tried per rectum. These injections are best given in 
starch water. Five-grain doses of sulphonal or trional, repeated in two 
hours if necessary, is sometimes very effectual. If there is no effect, then 
V24 grain of morphine may be administered hypodermically for a child 2 
years old. 

If the child is 1 year old, then 1 / 48 grain may be given, and repeated 
in several hours, if necessary. The greatest care must be maintained if 
haemorrhage exists. 

Bismuth is a very valuable drug; the subnitrate in 5 to 10-grain doses, 
and the beta-naphthol, in 5 to 10-grain doses, may be repeated every few 
hours as an antifermentative. 

Tannalbin or tannigen, in doses of 5 to 15 grains, can also be given 
every two hours. If the haemorrhage is very severe, then an injection con- 
taining 30 drops of Monsell's solution added to a quart of cool water, or 
a teaspoonful of alum, may be added to a pint of water. These injections 
can be repeated every three or four hours until the haemorrhage ceases. 
Ice-bags should be kept continuously on the abdomen at the slightest sign 
of haemorrhage. 

Guaiacol carbonate, in 5 to 10-grain doses, repeated every three or 
four hours, is a very good antipyretic. Creosote carbonate, 1 drop for 
each year ; for a child 1 year old, 1 drop ; for a child 5 years old, 5 drops, 
three times a day, is one of the best intestinal antiseptics. 

When severe tenesmus, associated with flatulence and very loose stools, 
exists, then the best remedy will be 1 or 2-drop doses of turpentine, com- 
bined with several drops of paregoric. The oleoresin of turpentine in 1 
or 2-grain doses, can be combined with 1 / 10 grain of extract of opium for 
a child, 5 years old, in the form of a suppository. This can be repeated 
several times a day if the symptoms are not improving. 



CHAPTER XIV. 
ERYSIPELAS. 

This is an acute infectious and contagious disease. It is characterized 
by an inflammatory condition of the skin, the subcutaneous tissue, the 
lymph spaces, and the lymph vessels. 

Etiology and Bacteriology. — We are indebted to Fehleisen for a study 
of the bacteriology of this disease. Fehleisen found the streptococcus 
present, so that it is positively identified as the cause of the same. The 
disease may also originate from a staphylococcus aureus. 







mm 




— 4k 



m 







m 




Fig. 221. — Ectogenotis Streptococcus Infection. Eczema and erysipelas 
of the scalp in a child 1 month old. (Bacteria carmine stain) ; (a) cutis; 
(&) subcutis ; (c) lymph vessels filled with streptococci, surrounded by an inflam- 
matory area ; (d) epithelial covering; (e, /) elevated horny layer; (g) strep- 
tococci. X 50. ( Ziegler. ) 

The invasion of the micro-organism takes place through an abrasion 
of the skin caused by scratching with a dirty finger-nail. It is very rarely 
epidemic, but can spread easily from patient to patient. A case of ery- 
sipelas is a source of great danger in a hospital ward. 
(702) 



ERYSIPELAS. 



703 



Pathology. — There is an infiltration of the tissues and they are usually 
swollen from an accumulation of serum. Under the microscope we can find 
pus cells in the serum. When this condition is noted abscesses will be 
found. In other cases gangrene will be present. There is nothing char- 
acteristic found in the lungs, heart, kidneys, spleen, or liver which would 
he distinctly pathognomonic. The usual conditions found in sepsis are seen 
here. 

P n e u m o n i a is 
sometimes met with as 
a complication. 

Symptoms. — The 
usual type of erysipelas 
met with in children 
is known as erysipelas 
migrans. This is known 
as the wandering type 
because it spreads rap- 
idly from diseased to 
healthy parts. The tem- 
perature in the begin- 
ning varies from 102° 
to 103° P., and may 
rise to 104° or 105° P. 
Septic cases usually 
show a much lower tem- 
perature. I have seen 
cases of a decided sep- 
tic nature in which the 
temperature was 99° F. 
for several days. The 
pulse-rate varies between 120 and 150. The flush is of a deep red color and 
usually very shining. The following case seen by me in consultation with 
Dr. B. Brodski will illustrate severe erysipelas : — 

Child M., 6 years old, suffered with severe coryza from acute rhinitis. There 
was an artificial eczema due to excoriation around the nose. The intense itching 
caused the child to scratch the parts and when the attending physician saw this 
case he found a well-defined erysipelas. Local remedies, such as lead and opium 
wash, and warm bichloride were used. The erysipelas spread over the face and 
at this time involved the eyelids so that the eyes were tightly closed. The fore- 
head, nose, and cheeks were involved. This was the fifth day of the disease. 

Ten cubic centimeters of antistreptococcic serum were injected. The tem- 
perature at the time of injection was 103° F.; the following day the skin seemed 
to desquamate and lose its fiery red appearance. I also advised thorough inunctions 
of unguentum Crede, three times a day. With the aid of restoratives and good 



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Fig. 222. — Fever Curve in Facial Erysipelas. 
(Original.) 



704 



THE INFECTIOUS DISEASES. 



nutrition the ease recovered in about six days after the above treatment was com- 
menced. Xo complication ensued, although at one time meningitis was suspected. 

Another case equally instructive was seen by me in consultation with Dr. 
Henry M. G-roehl : — 

Baby K., 1 year, was seen on her fifth, day of illness by Dr. Groehl, who found 
a well-marked case of erysipelas involving both the lower extremities. The tempera- 
ture was 104 V 5 ° F. The child was very restless. The flush spread to the back 
and over the abdomen. He ordered locally lead and opium wash to cool the surface, 
and internally he gave calomel and phenacetin with sparteine. 

On the sixth day the child was much improved. Temperature fell to 99° F. 
pulse was good. On the seventh day there was a marked change for the worse. The 
temperature still remained at 99° F., the pulse was rapid and feeble; there was con- 



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Fig. 223— Fever Curve in Phlegmonous Erysipelas. (Original.) 



tinuous vomiting. The inflammation suddenly spread from the abdomen to the 
chest, almost covering the child. The appearance was decidedly septic. The 
child vomited long after all drinks by the mouth had been stopped. In fact, 
long after rectal feeding had been commenced the vomiting persisted. 

On the eighth day of the illness I saw the ease, and after going over the history 
and treatment, recommended injections of 10 cubic centimeters of antistreptococcus 
serum. This was injected in the usual aseptic manner, just as we inject antitoxin. 
On the evening of the same day of the injection there was no reaction. The child 
continued the same. 

The following day, about three hours before the exitus lethalis, the body was 
covered with ecchymotic spots. The various parts of the body were covered with 
discolorations, some of them resembled the colors of the rainbow. 

Complications. — The oedema usually seen on the skin is a very fatal 
complication in erysipelas affecting the air passages. In such cases oedema 
of the glottis will result fatally. 

Prognosis. — This depends upon the time when the case is first seen 



ERYSIPELAS. 705 

and chiefly upon the condition of the child at the time of the infection. 
[f the child is well nourished and has been breast-fed 3 the prognosis is good. 

Treatment. — A dose of rhnharb and soda or 5 to 1<> grains of phos- 
phate of soda should be given. The destructive tendency of the pathogenic 
bacteria on the blood should be remembered ; hence large quantities of nor- 
mal saline solution should he given, hy injection, into the colon. The 
Btricteal hygienic measures must be used. The internal administration of 
active diuretics, such as spirits nitr. dulc, is indicated. The strength of 
the child should be supported with proper food, so that it can throw off 
the poison. The most effectual treatment is the local treatment, especially 
if fever exists. 

Local Treatment. — Pure alcohol in which bichloride of mercury is 
dissolved should be applied continuously by saturating absorbent cotton 
and laying the same over the erysipelatous flush : — 

ft Alcohol 2000 parts 

Bichloride of mercury 1 part 

In some cases lead and opium wash is very cooling and will remove 
the heat from the affected parts. 

Oil silk or rubber tissue should cover the wet application to prevent 
evaporation. The inunction of a 10 per cent, ichthyol ointment has been 
tried by me with some success. I regard the use of Crede ointment as a 
very efficacious remedy. 

Collargolum (Soluble Metallic Silver). — In septic scarlet fever and 
in severe types of erysipelas in which a profound toxaemia exists, rectal 
injections consisting of collargolum 214 to 4% grains and aq. dest. 2y 2 
ounces are useful. 

Magnesium Sulphate (Epsom Salt). — In severe cellulitis and erysipela- 
tous inflammations a solution of 

ft Magnesia sulphate 2 drachms 

Aqua 16 ounces 

is to be applied as a lotion. 

Excellent results have been seen by me after several days' application in 
severe cases of erysipelas at the Willard Parker Hospital. Associated with 
this local treatment active catharsis and liquid diet with plenty of water 
internally and fruit juices are indicated. 

Serum Treatment. — Since the streptococcus has been found to be the 
etiological factor in erysipelas, the most plausible treatment has been the 
antistreptococcic serum. The clinical cases described, in this chapter show 
very good results from the serum treatment. I have seen specific results 
after using 10 to 20 cubic centimeters of this serum, and strongly advise 
the use of the same in this disease. 1 



^ead also clinical report of case of erysipelas complicating varicella in chapter 
'Varicella," page 678. 



is 



CHAPTEE XV. 

MALARIAL FEVER (INTERMITTENT FEVER— PALUDAL FEVER— AGUE). 

This is a specific infections disease due to the invasion of a distinct 
germ belonging to the class of protozoa. It is known as the plasmodium 
malarias. "The disease is contracted by the inoculation of the human sub- 
ject by the infected mosquito. The plasmodium malarias passes through 
one cycle of its development in the body of a variety of the mosquito known 
as the anopheles cleviger." 

We find this disease in Southern Eussia and in Italy; in our own 
Southern States as well. In the North of Europe and the North of Amer- 
ica it is rarely found. The disease is usually seen in swampy regions and 
where bad drainage exists. It is also seen in the tropics. The influence of 
the weather is interesting. While in summer, spring, and fall cases occur 
frequently, in extremely cold weather they are very rare. 

Bacteriology and Etiology. — Laveran, in 1880, discovered the specific 
germ which causes this disease in the blood of infected individuals. In 
America, Councilman, Abbott, Osier, and many others have confirmed 
Laveran's observations. There are several types of fever. 

First. — The middle forms: (a) tertian, double tertian (quotidian); 
(h) quartan fever and its combinations. 

Second. — The more severe, often more or less irregular fevers which 
occur in America and in Italy, most commonly at the end of the summer 
and fall, called the asstivo-autumnal fever of the Italians. The tropical ma- 
laria of the Germans. This type of fever includes the so-called remittent 
malarial fevers as well as most of the cases of pernicious malaria and other 
malarial cachexias. 

Tertian Fever. — Golgi's description and differentiation of the micro- 
organism of the tertian and quartan type of malaria have remained prac- 
tically unassailed. "If we examine the blood from a case of tertian fever 
just after the paroxysm, we find in certain of the red blood-corpuscles 
small, round, colorless bodies which appear to have a slight depression in 
the center, and when stained in dry specimens show a paler central area 
with a darker periphery. These bodies examined in the fresh specimen 
show active amoeboid movements. A few hours later the organism will be 
found to have increased somewhat in size, and to contain a few, fine, 
brownish pigment granules which dance actively under the eye, the motion 
probably being due to undulatory movements in the protoplasm. On the 
day between the paroxysms the bodies will be found to have about half- 
filled the red corpuscles. They are still actively amoeboid, and the number 
of pigment granules has considerably increased. The red corpuscle at this 
stage will be seen to be a trifle larger than its unaffected neighbors, and to 
(706) 



MALARIAL FEVER. 



■07 



nsiderably decolorized. On the day of the paroxysm the organism has 
entirely filled and almost destroyed the red blood-corpuscle, which ifi 
resented only by a faint pale rim about the full-grown parasite, if, indeed, 

it has not entirely disappeared. The pigment granules may show at this 
stage a very active motion, but the amoeboid movements of the organism 

as a whole are but little marked. At the time of the paroxysm an inti 

_ hange takes place: the pigment gathers together in a more or less 
solid clump, usually in the center of the organism, while the rest of the 
protoplasm looks somewhat granular and shows a suggestion of lines radiat- 
ing outward from the center. This appearance gradually changes, the lines 
becoming more distinct, until finally we see the central clump of pigment 
surrounded by from fifteen to twenty small ovoid or round glistening seg- 
ments, each one having a central more refractive spot, and resembling 




Fig. 224.— Malaria Plasmodia: Ter- Fig. 225. 

tian Type. Plekn-Ckenzinsky's Stain. ical Form. 

X 1000. X 1000. 



-Malaria Plasmodia : Trop- 
Rornanowskv-Xocht Stain. 



strongly the hyaline bodies which we see immediately following the chill. 
This segmentation of the organism is always coincident with the paroxysm, 
and the presence of the blood of a segmenting body is a sure indication 
that the paroxysm is present, or is about to occur. Immediately following 
the paroxysm fresh hyaline bodies appear in the red corpuscles. Though 
the invasion of the corpuscles by these fresh segments has never been 
actually observed, the evidence that this occurs is so strong that we can 
safely accept it as a fact. Besides these forms we see not infrequently small 
or large extra cellular pigmented bodies; that is, organisms resembling 
exactly those within the red blood-corpuscles, excepting that they are free 
in the blood current. 

These may be seen at times to break up into several smaller bodies, 
while at other times they may show a long, tail-like, non-motile process 



'OS 



THE INFECTIOUS DISEASES. 



containing sometimes a few pigment granules. They are probably organ- 
isms which have escaped from the red corpuscles, or full-grown bodies 
which have broken up: they are considered to be degenerative forms. At 
times also we find the so-called flagellate bodies. Their development from 
the pigmented organism may indeed be observed, the pigment of the full- 
grown body becoming very actively motile, then collecting in the center 
of the organism, while several long, thread-like flagella burst out of the 
body and move actively about among the surrounding corpuscles. Some- 
times we may see one of these flagella which has broken away from the 
organism and is moving rapidly through the field. This is also thought 
by the Italians to be a degenerative process. The characteristics of this form 
of organism, which is observed in tertian fever alone, are so marked that 
with a little study of the parasite one can make a definite diagnosis of the 
type of fever from an examination of the blood alone. 



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Kg. 226. — Tertian Fever (Intermittent Fever). Typical malarial tem- 
perature, usually seen in the spring and early summer. Onset "with vomit- 
ing, diarrhoea and chills, accompanied by a well-marked rigor, and coldness 
of the extremities. (Original.) 



The Parasite of Quartan Fever. — ''Quartan fever is not at all common 
in this country, but in the few cases which the writer has observed the or- 
ganisms differ distinctly from the tertian parasite, and show accurately the 
characteristics described by G-olgi. Here the first stage of the organism is 
similar to that observed in tertian fever, excepting that the amoeboid move- 
ments are not so active. As the body develops, the rods and clumps of pig- 
ments are larger and darker than those in tertian fever, while the amoeboid 
movements of the organism are relatively slight. The full-grown forms are 
materially smaller than in tertian fever, while the red blood-corpuscles, 
instead of being expanded and decolorized, appear at times shrunken about 
the body, and of a somewhat deeper old-brass color (messingfarbe). In 






MALARIAL FEVER. 



709 



segmentation the organism divides into from six to ten different parts in- 
stead of twenty to thirty, as in the tertian form. 

The Organisms of the JEstivo-autumnal Fevers. — "The organisms asso- 
ciated with the Kstivo-antumnal fevers have been carefully studied, but 
much remains to be done, particularly in this country. 

"There is some difference of opinion as to whether there are not two 
types of organism associated with these fevers. Some Italian observers 
divide them into the quotidian and the malignant tertian organisms. The 
differences made out by the Italians are, however, very slight, and have not 
been observed in this country. In the first place we see just after the 
paroxysm small hyaline bodies which may or may not be actively amoeboid; 
these can sometimes be distinguished in that they are generally somewhat 
smaller and have oftentimes a characteristic ring-like appearance. In the 
early stages — during the first week, for instance — of an attack of this form, 



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Fig. 227. — Quartan Fever (Double Tertian). Onset with vomiting and 
convulsions. Convulsions usually accompany each paroxysm. Restlessness 
associated with cyanosis and coldness of extremities. These cases are usually 
seen in the late autumn. (Original.) 

we may see only the hyaline, unpigmented forms; but commonly, if we 
observe carefully, we ma}^ see some time after the exacerbation of tem- 
perature, shortly before the beginning of another, bodies which are a trifle 
larger than these smallest hyaline forms and which contain one or two very 
minute pigment granules lying near the periphery. Just before or during 
the paroxysm we may see bodies with a small central clump of motile or 
non-motile pigment granules lying usually in cells which are more or less 
shrunken and crumpled, and of a deeper color than the normal corpuscles 
(messingfarbe). These bodies are generally not half as large as the red 
corpuscles. After the first week or ten days of the disease, or after treat- 
ment has been begun, we see, however, certain very characteristic and easily 
recognizable forms which are only seen with this type of fever. These are, 
first, round or ovoid bodies about the size of a red corpuscle, a little smaller 
or a little larger, with clear, rather highly refractive, waxy-looking proto- 



710 



THE INFECTIOUS DISEASES. 



plasm, and coarse dark pigment granules, which are usually collected in a 
ring or a mass in the center of the organism. The granules are usually very 
slightly motile. At one side of the body we often see a small bib-like attach- 
ment which may show a slightly yellowish color. On examination this proves 
to be the remains of the red blood-corpuscles in which the organism has de- 
veloped. In association with these are seen crescentic bodies, the proto- 
plasm of which shows the same characteristics as that in the forms above 
described, while the pigment is collected in the middle in a similar ring 
or bunch, and is but slightly motile. On the concave side of these crescents 
one may also often see a bib-like attachment, just as in the ovoid forms. 
At times during the examination of the fresh specimen we may see the 
change from an ovoid body into a crescent take place. The development of 



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Fig. 228. — iEstivo-autunmal Fever (mild type). Ushered in with vomit- 
ing, restlessness and flushing. The spleen is enlarged. Either delirium or 
drowsiness and somnolence exists. (Original.) 



these forms from the hyaline bodies can be followed out on careful ob- 
servation. They are thought by some to be a resting stage of the organism. 
Segmenting bodies are almost never seen in the circulating blood of this 
form of malarial fever, though the presence of the round intracellular 
bodies with central pigment is a sure sign that segmentation is going on 
elsewhere. It has been found by the Italians that after the accumulation 
of a few pigment granules the organisms seek the internal organs, where 
segmentation takes place. The bodies are still small and contained within 
the red corpuscles. The pigment gathers in the center, as in the other types 
of segmentation, while the segments are very small and rarely more than 
twelve in number. During the paroxysm we may see large numbers of leu- 
cocytes containing pigment granules and clumps which are probably the 
remains of segmenting organisms. Flagellate bodies may be observed here 
as in the tertian and quartan fevers, but only when ovoid and crescentic 
pigmented bodies are present. They may be seen to develop from the round 



MALARIAL FEVER. 711 

bodies with central pigment Carefu] studies concerning the morphological 
characteristics of the malarial parasite have shown that it belongs to the 
elass of protozoa, ami is possessed of a nucleus containing one or more 
nucleoli. At the time of sporullation this nucleus divides — according to 
some — directly, according to others by karyokihesis." 

Pathology. — In fatal malaria the following changes are found: — 

The spleen is enlarged; the capsule tense. Death has been reported 
from rupture of the spleen (Thayer). The pulp of the spleen contains large 
numbers of red blood-corpnscles in which the characteristic parasite is 
found. "The capillaries are usually filled with the plasmodia, while the 
splenic veins show relatively few, though they always contain large cells 
enclosing pigment or the remains of red corpuscles. 7 ' 

The Liver. — Small areas of necrosis are described by Guarnieri : "Nu- 
merous liver cells are found containing clumps of haematin and altered 
red corpuscles, a condition similar to that found in pernicious anaemia. 
Bignami believes that this may explain the polycholia found in cases that 
died of pernicious malaria." 

Examination of the Blood. — A small drop of blood should be taken 
from the ear or from a finger tip. The usual aseptic precautions, such as 
carefully washing the finger with soap and water, followed by a washing 
with alcohol or ether, should be strictly carried out. Fresh blood must be 
examined soon after it has been withdrawn — no later than three or four 
hours. A film of blood can be preserved if the air is excluded by smearing 
vaseline around the edges of the cover glass. The amoeboid movements of 
the protozoa can be studied in this fresh blood. Blood for examination 
should be drawn about one hour before the expected paroxysm. The or- 
ganisms are much smaller after a paroxysm. 

"The tertian parasite completes its life in about forty-eight hours, or 
less, if there is any variation from this time. In the first twelve hours of 
their life the parasites appear as small, clear specks (hyaline bodies) in the 
red corpuscles, and if any pigment is to be seen it is as very small granules. 
If stained they appear pale blue. They are actively amoeboid, and remain 
so for about an hour after withdrawal. In the next twelve hours the para- 
sites have grown to about one-third the size of the corpuscle, are still 
amoeboid, show fine granules, and the corpuscle has become paler. In 
the next twelve hours the parasites have taken up about two-thirds of the 
cell, have become less amoeboid ; the granules larger and moving. The 
parasites are now more irregular in shape, and the corpuscles larger and 
paler, the pigment granules standing out more markedly. In the next 
twelve hours all motion ceases, the corpuscles become shells, the centers 
of which are occupied by the parasites, and spore formation and segmenta- 
tion begin. The organisms break up into fifteen or twentv round spores, 
at first contained inside the cell-wall of the red corpuscles, and then set free 



712 THE INFECTIOUS DISEASES. 

into the blood. It is at this time that the clinical paroxysm occurs. All 
hyaline bodies do not develop to the stage of spore formation, nor do all 
these spores — really the young hyaline bodies — which have been set free 
into the blood serum re-enter the red corpuscles, but the blood plasma 
itself destroys many of them. 

"Should we have under observation clinically a quotidian form of 
malaria, the red corpuscles would show the tertian parasite in but two stages 
of development, one group being approximately twenty-four hours older 
than the other ; of course, depending upon the hour at which the paroxysms 
occur. This is due to a double infection. It must not be forgotten, however, 
that we may have a triple quartan infection that produces daily paroxysms. 

"The quartan parasite grows in seventy-two hours. In the first twelve 
hours it is a very small, unpigmented, slightly amoeboid, hyaline body, be- 
coming in twelve hours more about the size of one-sixth to one-fifth that 
of the corpuscle, having taken on a few pigmented granules placed peri- 
pherally. In forty-eight hours it is one-half to two-thirds the size of the 
red corpuscle, round, as a rule, and possessing no amoeboid movement. In 
sixty hours from the paroxysm, it occupies nearly all of the corpuscle, 
which is neither enlarged nor paler than normal. In six hours more the 
pigment granules approach the center and are arranged like the spokes of 
a wheel, the first sign of segmentation. About three hours before the at- 
tack, segmentation has produced from six to ten oval or pear-shaped bodies 
or spores containing pigment in their centers. In multiple infections of 
this type we, of course, find the organisms in the blood in different stages of 
development. Flagellated bodies develop after the blood is removed from 
the body, and consist of a central cell with arms thrown out. These arms 
are freely movable. In examining a fresh specimen, we may see such a 
body keeping up a constant ciliary motion and causing a disturbance in the 
arrangement of the red cells in its immediate neighborhood. The flagellated 
body does not often appear in either of the foregoing types of the infection, 
but is more common in the sestivo-autumnal variety. The second group of 
parasites belongs to the class of malignant or sestivo-autumnal figures, and 
are divided into, -first, the pigmented quotidian parasite; second, the un- 
pigmented quotidian parasite; and third, the malignant tertian. 

"The pigmented quotidian parasite completes its cycle in twenty-four 
hours. When seen in the blood-corpuscle, it appears as a small actively 
amoeboid, hyaline body, rapidly becoming pigmented and quiet, the pigment 
lodging in the periphery of the organism, after which it breaks up into 
spores. It has been pointed out that segmentation of this type does not take 
place in the peripheral blood, but occurs in the spleen and bone marrow. 
The pigmented organism occupies one-third of the corpuscle which is 
shrunken, if changed at all. After the infection has lasted for several days 
crescents appear. 



MALARIAL FK\ ER. 



713 






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714 THE INFECTIOUS DISEASES. 

''Crescents are always an evidence of cestivo-autumnal fever, and never 
occur in the quartan or tertian type. They are from eight to ten micro- 
millimeters in length and from two to three micromillimeters in breadth, 
are half-moon shaped when typical, but vary greatly, oftentimes appear- 
ing almost straight. They contain pigment sometimes scattered, but 
oftener found clumped in the center, and usually without motion- With 
a good light and an accurate adjustment the shell of the red blood-cor- 
puscle can be seen extending from the poles of the crescent, showing that 
this parasite is distinctly an intracellular formation. Crescents are dis- 
tinctly an evidence that the infection has lasted a number of days, — five or 
six — and they will not be found in any specimen before that time. The 
unpigmented quotidian parasite shows not many variations from the fore- 
going type, except that it is free from the pigment, though the crescents 
formed from this variety may show pigmentation. The malignant tertian 
parasite is pigmented and, in fact, much like the jngniented quotidian. It 
grows to segmentation once in forty-eight hours, and is amoeboid in the ad- 
vanced stage : the pigment is active and the entire organism is larger. Prob- 
ably no better idea can be given concisely of the different characteristics of 
these parasites than by reproducing the table of Mannaberg." (See p. 713) . 

Symptoms. — In very young children there may be convulsions, restless- 
ness, cold extremities, and yawning. The pulse is full and rapid. The tem- 
perature may reach as high as 105 c F., or even higher. After this febrile 
stage the body is coiered with a profuse perspiration, ending in sleep from 
exhaustion. Diarrhoea is ocasionally met with in this condition, and is prob- 
ably the result of secondary infection. Bronchitis is occasionally seen. The 
paroxysm of fever occurs when the protozoa matures and begins to divide. 
This process repeats itself about every twenty-four hours in the tertian type 
of intermittent fever most frequently seen in this country. If children 
are carefully observed, then the onset of a paroxysm is frequently seen 
by a severe cyanosis affecting the nails. This would correspond to the 
chill seen in the older children. Slight albuminuria or hematuria fre- 
quently accompanies malaria. There is no disease that can be mistaken 
for the tertian type of malaria when it is remembered that there is a sick 
day with fever, etc., and an alternating apparently healthy day. 

An enlarged spleen is usually present. 

Diagnosis. — This can be most positively made by an examination of 
the blood. So many symptoms present in malaria, such as lassitude, pains 
in the bones, headache and fever, simulate other diseases, that only the posi- 
tive finding of Laveran's protozoa in the blood will complete the diagnosis. 

Differential Diagnosis. — If there is a doubt as to the differential diag- 
nosis between tuberculosis and malaria, the specific effect of a few doses of 
quinine will easily show the presence or absence of malaria. The blood test 
is. however, conclusive. 



MALARIAL FEVER. 715 

A boy, (I yours old, was brought to me at the children's service of the German 
Poliklinik with a history of headache, fever, and pain in the bones. The boy 
appeared rather icteric. His mother suid that he had lost weight during the last 
two weeks. He perspired freely, had a good day and a bad day. The fever appeared 
in the afternoon. The examination showed a well-nourished boy, lungs normal, a 
slight hemic murmur at the apex of the heart which was also heard in the vessels 
at the neck. The spleen was palpable and slightly enlarged. The appetite was poor, 
the bowels moved sluggishly. The child was restless at night. The examination 
of the blood showed the presence of the ordinary tertian parasite. Quinine in 3- 
grain doses was given every four hours, and 6 grains were given three hours before 
the expected attack, which in this condition was between 1 and 2 o'clock in the 
afternoon. Fifteen drops of cascara sagrada were administered before breakfast 
of each day. The treatment was continued for ten days. The boy then complained 
of buzzing in the ears, evidently due to cinchonism. Quinine was given every second 
day and Fowler's solution in 3-drop doses was administered on alternate days. 
Strengthening food was given and the child made a complete recovery. Quinine was 
given once every three days after the first month. The child took an ocean 
voyage and was perfectly well in two months. Iron was then given for several 
months as a tonic and the treatment discontinued. 

Prognosis. — This is usually good. If malaria is neglected severe an- 
aemia follows, and if pernicious malaria results it may end in death. In 
this country the specific effect of quinine and the change of climate usually 
gives successful results. 

Treatment. — A patient suffering with malaria should, if possible, be 
removed to a different climate. A change from the city to the country, 
or vice versa, is very beneficial. Next in importance to change of air is 
the specific effect of quinine. Five grains of quinine (0.3) can be given 
to a child 3 years old. The hydrochlorate of quinine is the most effective. 
Owing to its disagreeable taste it can be given in tablet form, after which 
a mouthful of coffee or chocolate can be given. When quinine is refused 
by mouth, then a 10-grain dose in the form of a suppository can be given 
three times a day, per rectum. The best time for administering quinine is 
about three hours before the expected attach. The bisulphate of quinine 
is a soluble and convenient form to use. It is very important to keep the 
bowels open and the kidneys active. Fifteen to 30 drops of fluid extract 
of cascara sagrada can be given in a palatable menstruum every morning, 
so that the action of the bowel is assisted. In true malaria, I have found 
especial benefit in administering whisky well diluted with water, or given 
in milk. Apart from its nutritive properties, it certainly has decided anti- 
septic properties. If malaria persists in spite of continued treatment, then 
arsenious acid in doses of 1 / 100 or 1 / 150 grain, can be administered three 
times a day. Fowler's solution, in doses of 1 to 5 drops, should not be 
forgotten. Jacobi recommends ergot in doses of 20 to 50 drops every day 
for weeks. When it is not well borne he combines it with quinine or arsenic. 
I have never been able to see the slightest benefit from the use of ergot, 
although I have tried it in many cases. I believe Jacobi's results were good 
when he combined the ergot with the quinine because the quinine was given. 



CHAPTEE XVI. 



SYPHILIS. 



This is a specific disease most probably caused by the invasion of a 
micro-organism. The disease in infancy is the same as that found in adults. 
There are two forms of the disease : — 

1. Inherited syphilis. 

2. Acquired syphilis. 

Etiology. — The most frequent modes of infection are : — 

By nursing from the breast of a .syphilitic wet-nurse. 

Eating from the dishes of syphilitic patients. 

Unclean surgical instruments; for example, when an infant is vac- 
cinated, or during the operation of circumcision. 

The Transmission of Syphilis in Utero. — An infant in utero may be 
infected directly through the circulation in the placenta. If the mother 
acquires syphilis during the ninth month of her pregnancy, the same will 
not infect her child nor modify its development. A healthy infant in 
utero can be infected by passing through a syphilitic genital tract of its 
mother during labor. 

When the ovum is infected with syphilis, which frequently happens 
at the time of conception, it may terminate in the death of the foetus, re- 
sulting in an abortion or in the birth of a still-born child. If the child 
lives it may suffer with cachexia, and a few weeks later present the char- 
acteristic skin-lesions. The father can infect the mother for three or, at 
the most, five years after his chancre. The father may infect the foetus as 
late as twenty years after his chancre, when for years he has presented no 
signs of syphilis. The mother may have a series of syphilitic pregnancies 
resulting in miscarriages or in syphilitic infants, without at any time 
herself presenting any syphilitic manifestations. In the same couple the 
severity of the infection transmitted to the foetus tends to decrease with 
succeeding pregnancies. Thus it is the rule for the mother to have at 
first several abortions, then a child born dead, and finally a living child 
showing the evidences of inherited syphilis. Children born later usually 
suffer less severely, but this 'law of decreases" (Diday) is not without nu- 
merous exceptions; sometimes the third or fourth child surfers more than 
the second. In other families children of one sex surfer more than those 
of the opposite sex. In twin pregnancies one may be affected while the 
other apparently escapes. The apparent escape of the mother of syphilitic 
infants by a syphilitic father has been accounted for on the supposition 
(716) 



SYPHILIS. 717 

that she undergoes a mitigated infection derived from the foetus. Coutts 1 
lias pointed out the theory that she absorbs From the foetus a syphilitic anti- 
toxin; this would account not only for her apparent immunity, hut also for 
the gradual decrease in the severity of the disease in later pregnancies. If 
the mother he infected but not the father, death of the foetus is the most 
likely result. If the child is born alive it will probably sutler from in- 
herited syphilis. If both parents have suffered from manifest syphilis, the 
chance of abortion or still-birth is greater. 

Colles's Law. — In 1837 Colles wrote that "A new-born child affected 
with inherited syphilis, even though it may have the specific lesions in the 
mouth, never causes infection of the breast which it sucks if it be the mother 
who nurses it, although continuing capable of infecting a strange nurse." 
The substantial truth of this dictum has not been seriously questioned, 
though various explanations have been offered. 

Is Inherited Syphilis Contagious? — The following interesting conclu- 
sions are based upon Eobert W. Parker's twenty years' experience in 
the East London Children's Hospital: — 

1. The children of syphilitic parents very frequently show manifesta- 
tions of a disease which is almost universally called "inherited syphilis." 

2. In a large proportion of the cases this inherited disease is not 
syphilis at all, in that the disease is non-contagions, and would be better 
named "inherited from syphilis." 

3. This inherited syphilis is true syphilis only if it conform to the 
ordinary tests which pertain to contact syphilis, and prove to be infectious 
and contagious. 

4. The children of syphilitic parents occasionally inherit syphilis. 

5. The mother suckling a child with such a disease may be infected 
by it. 

6. A healthy wet-nurse and other persons brought into contact with 
such a child are even more liable to be infected by it than the mother. 

7. Lymph taken from such a child, even although apparently well at 
the time, will probably, or possibly, invaccinate syphilis. 

8. In reply to the question: "Can a healthy woman give birth to a 
syphilitic child?" the answer must be "No." 

9. Many women give birth to children who suffer from what is called 
"inherited syphilis," without themselves appearing to be infected. The 
explanation is obvious : this "inherited syphilis" is not syphilis in the true 
sense, and the mother's so-called escape depends upon this fact. 

10. There is no recent clinical evidence which fully realizes Colles's 
teaching, viz. : a mother suckling her own syphilitic infant and escaping 
an infection to which a healthy wet-nurse suckling the same infant, and 



1 "Some Aspects of Infantile Syphilis." Hunterian Lectures, London, 1897. 



718 



THE INFECTIOUS DISEASES. 



other members of her family who have merely handled this infant, have 
succumbed, the latter facts being essential if only to establish the contagi- 
ousness of the infant's disease in any and every given case asserted to be 
"inherited syphilis." 

Pathological Anatomy. — In acquired- syphilis changes are the same in 
the child as in the adult. 

In hereditary syphilis there are certain constant changes present in 
the bones. These changes are confined to the shafts of the long bones and 
to the cranial bones. 




Fig. 229. — {A) Spirochete Pallida; (B) Spirochete Refringens from a 
case of Syphilis. First described by Schaudinn and Hoffmann in Berlin in 
May, 1905. There is no question but that the above parasites are the 
causative agents of syphilis. This specimen was obtained through the kind- 
ness of Dr. Boas, of Berlin. (Original.) 



The pathological changes are not confined to the epiphyses, but the 
diaphyses are also swollen. The ends of the bones are swollen. The inner 
portion of the periosteum shows swelling and hyperemia. 

The circulatory apparatus shows thickening of the arterial walls as 
well as of the veins. Owing to this degeneration there is a tendency to 
bleeding. (See clinical case described in this chapter.) 

Catarrhal manifestations showing implication of the respiratory tract, 



SYPHILIS. 719 

and also the gastro-intestinal tract, can be noted. The liver, spleen, and 
pancreas are enlarged. 

The lymph glands of the entire body are enlarged. 

Symptoms. — When catarrh is troublesome in children and not amen- 
able to ordinary treatment, syphilis should be suspected. It is surprising 
to find the frequency with which nasal and nasopharyngeal catarrh is asso- 
ciated with syphilis. 1 have not yet had occasion to regret asking a direct 
question of a parent in whom I suspected syphilis, if such parent is told 
that we must know his previous history, for the benefit of his child. 

Gastrointestinal Tract.*-^ The gastro-intestinal tract is the one that 
will frequently show the manifestations of syphilis. An infant will not 
appear to thrive nor will it digest, in spite of the most careful dietetic meas- 
ures. Syphilitic lesions of the liver, pancreas, stomach, and intestine are 
simply all part of the infection. Anti-luetic treatment will frequently do 
more good in a few days or weeks than months of rigid diet. Thus it is 
apparent that in order to do good in this disease we must seek to remove 
the cause. 

When a persistent diarrhoea will not respond to the ordinary treat- 
ment of careful diet and medication, then suspect syphilis. When diar- 
rhoea such as a mucus-colitis persists without fever after careful dieting, 
then syphilis may be suspected. 

The following case will illustrate congenital syphilis : — 

An infant about one week old was seen by me. It was the fourth child of 
apparently healthy parents. Three children had previously died, and this fourth 
child "was born at full term. The mother noticed that the child cried incessantly and 
was very restless. The child had had sniffles since birth. It was breast-fed and 
appeared to suffer with colic and hunger. The stools were grass-green and con- 
tained mucus and curds. The palms and soles had a pemphigus. The skin had a 
yellowish tinge. The nose was excoriated from the discharge. The anus had deep 
cracks — the so-called rhagades. Around the mouth were also rhagades. The 
spleen was enlarged and palpable. The lymph glands were not enlarged. The child 
did not seem to thrive. The finger nails showed distinct evidences of the disease. 
The bones of the fingers and toes showed the presence of dactylitis syphilitica. The 
diagnosis of congenital syphilis was made. The mother had plenty of milk, but 
was compelled to wean the child owing to a typhoidal condition to which she suc- 
cumbed. The infant was bottle-fed, and when about five weeks old developed a large 
abscess on the forearm which was incised under an anaesthetic by Dr. Geo. F. Shrady. 
One week later a series of metastatic abscesses formed over the abdomen and on 
the back. The child died from inanition and general sepsis when about nine weeks 
old. 

Hcemorrhages from the nose and mouth, and bloody stools due to ulcer- 
ation of the intestinal tract are frequently reported. 

Uracek has reported haemorrhages in the different internal organs 
caused by syphilis in the infant. Umbilical haemorrhages are sometimes 
due to syphilis, according to Eotch. 



720 THE INFECTIOUS DISEASES. 

The following case will illustrate bleeding in the new-born : — 
An infant suffered with a severe form of marasmus and athrepsia. It did not 
develop. Examination of the mucous membrane of its mouth, gums, and fauces 
showed distinct patches. The child was attended by Dr. Honor, of New York City, 
who referred the case to Dr. W. Freudenthal for diagnosis. The case was also seen 
by me and I concurred in the opinion expressed, that the patches were non- 
diphtheritic and were most likely due to syphilis. Several days later Dr. Freudenthal 
and myself were again called to see this child owing to an extensive nasal haemor- 
rhage. In spite of the most active local treatment, the use of haemostatics, such as 
adrenalin, and the use of styptics internally and externally, the infant died from 
exhaustion. The attending physician, Dr. Honor t subsequently stated that he had 
found distinct evidence of syphilis. 

Shin Lesions. — The skin lesions develop soon after those of the mu- 
cous membrane. The eruption consists of small, round, pink macules, which 
disappear on pressure. While the eruption may be on the abdomen and 
lower limbs, it not infrequently is found all over the body. At times the 
eruption resembles an erythema and is copper-colored. Sometimes the 
eruption is papular; it is not infrequent to find condylomata around the 
mouth or anus. These condylomata are very contagious. Pustules are 
frequently seen as early as two months. This eruption can be differentiated 
from eczema by the characteristic absence of itching that always accom- 
panies eczema. Furuncles are usually found in poorly nourished children. 
The infant usually has the appearance of a shriveled old man. 

The Teeth. — The teeth in congenital syphilis, instead of appearing at 
the sixth or seventh month, may not appear until the fourteenth or fif- 
teenth month, and even later. These teeth are usually carious. 

Congenital Syphilitic or Hutchinson's Teeth. — This variety of dental 
abnormality is important, because, as Hutchinson says, "It is, if taken 
alone, by far the most valuable of the signs by which we recognize in 
adolescence the effect of inherited syphilis." The characteristics of these 
teeth are not sufficiently known, and abnormal and peculiar teeth of other 
kinds are often erroneously regarded as proofs of congenital syphilis. The 
main points about "Hutchinson's teeth" are as follows : — 

1. It is always the permanent teeth which are affected. The tem- 
porary teeth in syphilitic infants often decay early, but they present no 
special peculiarities of form. 

2. The characteristic peculiarities which distinguish these central 
incisors are as follows : They are dwarfed, being too short and too narrow ; 
and sometimes the portion of the upper jaw from which they grow is also 
arrested in growth. They often stand somewhat apart and slope toward 
one another. They are unusually rounded on section; they are "pegged" 
and they are notched. The notch is usually shallow and the dentine is 
exposed at the bottom of it. It is formed by the breaking away of the 
imperfectly developed central portion of the edge. The teeth are generally 



SYPHILIS. 721 

not of a good color, and they are abnormally soft, so that by the time the 
patient is 20 they may be ground down like those of an old man. 

The first molars are next in diagnostic importance to the upper cen- 
tral incisors. When characteristic they are spoken of as "dome-topped." 
Their sides slope toward the center, over which the enamel is defective. As 
might be expected, syphilitic teeth not infrequently present the character- 
istics of mercurial teeth in addition to their own peculiarities. 

Diagnosis and Differential Diagnosis. 1 — The clinical history will be the 
guide in congenital syphilis. The history of previous abortions and still- 
born children will aid in establishing a diagnosis. 

Table No. 95. — Differential Points Between Syphilis and Tuberculosis. 

( Morrow. ) 

SYPHILIS. TUBERCULOSIS 

Exhibits a marked predilection for the Is almost exclusively situated in the 

long bones; its habitual localization is epiphysis, rarely affecting the shaft. 
in the diaphysis and almost always at 
its terminal extremity. 

There is a marked enlargement of the The tumefaction is due less to increase 

bone by more or less voluminous osseous in the size of the bone than to cedematous 

tumors or hyperostoses, with little or no infiltration of the soft structures, 
involvement of the soft parts. 

There is little tendency to suppuration The pyogenic tendency is marked, 
and necrosis. 

Osteocopic pains with tendency to The pain is dull and heavy, not aggra- 
nocturnal exacerbation are pronounced vated at night; sometimes there is en- 
features, tire absence of acute painful symptoms. 

The osseous lesions rarely react upon The osseous lesions often determine a 

the general system. marked impairment of the general 

health, grave complications, hectic fever, 
cachexia, etc. 

In dactylitis there is little involvement In dactylitis the swelling is due more 

of the soft parts, the swelling being to an cedematous infiltrated condition of 

caused by the enlargement in the size of the soft tissues than to enlargement of 

the bone. the bone. Breaking-down of the tissues 

and ulceration are more apt to ensue. 

The cachectic skin, the wrinkled mouth, and rhagades at both mouth 
and anus will materially aid in establishing a diagnosis. 

At times pseudo-paralysis will be present; sometimes coryza, hoarse- 
ness, inflamed eyes, and persistent running ears. 

The Wassermann Beaction. — In suspicious cases the blood should be 
examined to see if we get a positive Wassermann reaction. 

"The diagnosis between syphilis and rachitic bone lesions may become 
of great importance. Epiphyseal swellings occurring under six months are 
apt to be syphilitic. In syphilis the epiphyseal swelling may be unilateral, 



1 See "Blood in Syphilis," paj 



722 



THE INFECTIOUS DISEASES. 





Fig. 230. 



Fig. 231. 





Fig. 232. 



Fig. 233. 



Figs. 230, 231, 232, 233.— Syphilitic Teeth. Various types of hereditary 
syphilitic teeth, as described by Hutchinson, also parenchymatous keratitis. 
Note that the upper central incisors show the positive evidence of syphilis. 
(Courtesy of Dr. Hugo Neumann.) 



SYPHILIS. 



723 



but it is always symmetric in rachitis. In doubtful cases the swelling must 
be subjected to specific treatment. Rickets and syphilis may co-exist in the 
same case. There is almost invariably enlargement at the costochondral 
articulations in all cases of rickets, which is absent in syphilis." 

Prognosis. — This depends upon the condition of the child at the time 
treatment is commenced. Such children have very little or no vitality. 

Hereditary syphilis can be transmitted to healthy children, so that 
the precaution of strict isolation should be remembered. 

Treatment. — The therapy of syphilis has undergone a radical change 
since the introduction of salvarsan. Through the courtesy of Prof. Ehrlich, 




Fig. 233a. — Congenital Syphilis Before Injection of Salvarsan. (Original. 



of Frankfort, I received a liberal supply of salvarsan, also known as 
dioxydiamidoarsenobenzol or "606." 

No case should be injected until a positive Wassermann reaction has 
been obtained. The choice of the technique of the injection is one of 
preference, although the intravenous method seems most popular because 
of better results. The following doses are recommended : For an infant 1 
year old, an injection of 0.06, to be followed in one week by an injection of 
0.1 (intravenous method) if no severe systemic reaction follows the first 
injection. For a child 5 years old an injection of 0.1, followed one week 
later by an injection of 0.2. Complications must be guarded against. 
When we recall that one-third of salvarsan consists of arsenic then the 
toxicity of the same is well brought out. By the intravenous method we 
diffuse the efficiency of this drug into the circulation and prevent the 
cumulative effect which usually follows the intramuscular injection. 



724 



THE INFECTIOUS DISEASES. 



In one of my cases 1 severe necrosis of the tissues in the gluteal region 
was followed by a series of deep abscesses. In addition thereto a multiple 
neuritis developed which involved the lower limbs and persisted until five 
months after the injection was given. The syphilitic ulcerations and 
condylomata around the vagina and anus improved after three or four days 
and practically disappeared. This child was 18 months old and received 
0.3 of an alkaline solution of salvarsan injected into the gluteal region. 

B. L., six years old, a former patient of Dr. Tunick, was admitted to the 
babies' ward of the Sydenham Hospital. The mother had an innocent infection. 




Fig. 233&. — Appearance of Lesions One Week After Injection of Salvarsan. 

(Original.) 

The child showed distinct evidences of syphilis. Two years previous a gumma of 
the left testicle existed, and said testicle was removed. At time of admission he 
had very marked superficial veins, periostitis, and gumma of the left knee-joint. 
The Wassermann reaction and the Noguchi reaction were positive. All serological 
examinations were made by Dr. D. M. Kaplan. 

One injection of 0.3 salvarsan, in a neutral solution, was given, with aseptic 
precautions in the left buttock. No local reaction followed. The child made a 
brilliant recovery. The swelling in joint subsided after three days. The boy walked 
in one week and was discharged two weeks after admission. 

Technique. Kromayer's Method.— According to Kromayer's method, 
the drug is rubbed up in a mortar with sterile liquid paraffin so that a 10 

1 Reported in the Journal of American Medical Association, February 11, 1911. 



syphilis. 725 

per cent, suspension is made. The injection is given either into the gluteal 
or into the pectoralis muscle. 

Goldenberg's Method. — This method consists in dissolving 0.1 salvarsan 
in a 20 per cent, iodipin solution. Goldenberg states that this method is 
absolutely painless if injected into the buttock. 

Intravenous Method. — According to Schreiber's method, we take 0.2 
of salvarsan, add 3 cubic centimeters of warm sterile water to dissolve, 
then add, drop by drop, of a 15 per cent. NaOH solution, then warm 
sterile water to facilitate the rubbing. From y% to 1 cubic centimeter of 
the NaOH solution is necessary to dissolve 0.2 to 0.3 gramme of salvarsan. 
The total of the solution should not be more than 4 to 6 cubic centimeters. 

In using the intravenous method, prepare the salvarsan as above 
described, then add 100 cubic centimeters of physiological salt solution. 
The solution should be passed through a sterile filter and injected into a 
vein at the bend of the elbow. The solution should be kept during this 
time at about 100° F. Strict asepsis must be maintained. 

Local Treatment. — The safest method of administering mercury is 
in the form of bichloride baths. These baths can be given in a wooden 
tub, in which enough water is drawn to cover the child's body. From 5 
to 10 grains of bichloride can be added to this tub of water. Infants up to 
1 year can be bathed from ten to twenty minutes every day. 

The presence of eczematous or other skin eruptions would not contra- 
indicate giving these baths. 

The inunction of chemically pure mercurial ointment well rubbed into 
the axillae, knee-joints, or the thighs will materially aid in bringing this 
drug into the system. 

For the relief of syphilitic warts nothing is better than : — 

Ifc Bichloride 10 parts 

Alcohol 100 parts 

Apply with absorbent cotton several times a day. 

Internal Treatment. — Internally calomel and bichloride or the tannate 
of mercury can be given in suitable doses. It is advisable to give the child 
from 1 to 5 grains of iodide of sodium, according to age, to alternate with 
the mercurial treatment. 

Care should be taken that stomatitis is not developed in nurslings. If, 
however, stomatitis has developed, then active and persistent treatment with 
chlorate of potash solution, locally, will be found effectual. 

It is self-understood that hygienic treatment in addition to careful 
diet is just as important as the specific drug treatment. 

Feeding. — A diet of milk, eggs, cereals, fish, and fruit should form the 
basis of nutrition. The reader is referred to the chapters on "Marasmus" 
and "Kickets" as a guide to the method of feeding necessary to reconstruct* 
a weakened child. 



PART VIII. 

DISEASES OF THE BLOOD, GLANDS OR LYMPH NODES, 
AND DUCTLESS GLANDS. 



CHAPTER I. 
INTRODUCTORY. 



The Blood. 1 
The red corpuscles (also known as the erythrocytes). The red cor- 
puscles of the blood are more numerous at birth than in later life. Hayem 
and Helot found that when the umbilical cord was not tied until its pulsa- 
tions ceased, a greater number of red corpuscles were found than in cases 
where immediate ligation was performed. Leder and Hutchinson, com- 
paring the new infant's blood with that of its mother, found that the blood 
of the infant contained a larger number of red corpuscles. The following 
table will show the difference in blood count by various writers : — 

Table No. 97. 

Hayem averaged 5,360,000 

Sorensen " 5,665,000 

Otto " 6,165,000 

Bouchat and Dubrisay " 4,300,000 

Schiff (one case) .' " 6,658,000 

Gundobin " 6,700,000 

Elder and Hutchinson '•' 5,346,560 

Schwinge greatest at birth. 

The difference varies between 350,000 and 500,000 per cubic milli- 
meter. Gundobin believed that the concentration of the blood was caused 
by loss of water through the lungs. Schiff found the same condition; he 
also states that the number of corpuscles decreases when the child is put to 
the breast. The number of red corpuscles begins to fall after the second 
day. 

In one case Schiff studied the number in the morning and evening 
during the first fifteen days of life; he found the number declined irregu- 
larly. The first day's count was 7,628,000; the last day's count was 4,565,- 
600; the average for the fifteen days was 5,828,465. 

According to Schwinger and Gundobin there is a decrease in the num- 
ber during the first year, after this there is an increase up to the eighth or 

1 1 am indebted to Stengel and White, Archives of Pediatrics, April, 1901, for 
many valuable points in the preparation of this article- 

(726) 



THE BLOOD. 727 

twelfth year, when the number becomes approximately that of adult life. 
Sex makes no difference in the count of the red corpuscles in infancy. 

Size. — The red corpuscles vary greatly in size at birth and during the 
first few days of life. Hayem found variations between 3.25 ft to 10.25 ft 
and Loos found the size varying from 3.3 ft to 10.3 ft. Gundobin claims 
that the haemoglobin is more firmly attached to the cell stroma in the new- 
born infant. He also calls attention to the great number of small-sized 
corpuscles. 

The Haemoglobin. — According to Morse, Elder, Hutchinson, Taylor, 
and Eotch, haemoglobin is increased at birth, but the percentage declines 
rapidly during the first few days of life. According to Rieder there is an 
excess of 25 to 30 per cent, at birth compared with infants after feeding 
has begun. 

Specific Gravity. — This varies just like the haemoglobin. At birth the 
specific gravity is high. 

Monti found the specific gravity at birth 1060 

Rotch found the specific gravity at birth 1065 

Hoch & Schlessinger found the specific gravity at birth. 1066 

Moelle found the specific gravity at birth 1060 

The specific gravity may not vary for weeks or months in healthy 
children. 

The White Blood Corpuscles (Leucocytes). — Leucocytes are found in 
greater number at birth than in later life. This excess in number has fre- 
quently been spoken of as a normal condition. It is also called the 'physio- 
logical leucocytosis of the new-born. 

Table No. 98. — Table Showing the Variations in the Number of White Blood 

Corpuscles Found by Various Writers. 

Rieder 15,500 10 minutes after birth 

Rieder 16,500 8 hours after birth 

Rieder 8,700 Third day 

Rieder 3 cases, 13,600 Fourth day 

Rieder 2 cases, 10,500 Fifth day 

Rieder 3 cases, 12,200 Fifth day 

Oransky 16,980 Immediately after birth 

Oransky 20,980 20 hours after birth 

Oransky 31,680 44 hours after birth 

Cadet 19,480 Immediately after birth 

Grieffer 18,000 24 hours after birth 

Elder & Hutchinson, average 12 cases, 17,884 Immediately after birth 

After the second year the number gradually declines to that found in 
adult blood. Gundobin observed an increase of 2000 to 4000 leucocytes 
after feeding. The most striking peculiarity in the differential count is 
the increase in the number of lymphocytes and the more or less propor- 
tionate decrease in the polymorphonuclear cells. 



728 DISEASES OF THE BLOOD. 

Gundobin gives the following figures: Lymphocytes, 50 per cent, to 
66 per cent.; polymorphonuclear, 28 per cent, to 40 per cent. The weight 
of the child has no influence on the total number of leucocytes or on the 
proportions of the different forms. 

Pathological Conditions. — In disease the first change noticed will be 
a reduction in the percentage of haemoglobin, and also in the number of 
erythrocytes. There are smaller forms of red corpuscles called microcytes. 

Nucleated Red Corpuscles (E rythroblasts) . — These cells have been 
found in primary and secondary anaemias by many observers. They have 
also been found very abundant in syphilis, rachitis, tuberculosis, pseudo- 
leukaemia, and osteomyelitis. 

Leucocytosis. — In leucocytosis an increase in the number of leucocytes 
is found in the blood of anaemic children. It is also found in toxic and 
inflammatory conditions. Myelocytes are more frequently found in the 
blood of children than in adults. Cabot and Engel ascribe a bad prog- 
nostic significance in pneumonias and diphtherias to their presence. 

Infectious Diseases. — In diphtheria, scarlatina, pneumonia, and ery- 
sipelas the polymorphonuclear cells are greatly increased (Weiss and Gun- 
dobin) . Gundobin found an increase in the number of leucocytes before the 
eruption in scarlet fever, measles, and erysipelas. In typhoid fever the 
number of leucocytes is decreased; there may be also a decrease in the 
number of red corpuscles and in the percentage of haemoglobin. The num- 
ber of leucocytes is relatively increased. The polymorphonuclear cells are 
decreased. 

Pneumonia. — Leucocytosis is usually present in this disease. When it 
is absent the prognosis is grave. 

Syphilis. — In hereditary syphilis an anaemia is found with a decrease 
of the red corpuscles and great degenerative changes (poikilocytosis). In 
syphilis we find microcytes and macrocytes and nucleated erythrocytes. 
Myelocytes are also found. Eosinophiles are also met with in this condition. 

Bronchitis. — A slight leucocytosis with especial increase of the lympho- 
cytes or mononuclear cells. 

Gastro-intestinal Disease. — The condition of the blood varies accord- 
ing to the extent of the process, the duration, and the existence or non- 
existence of diarrhoea and vomiting. Profuse diarrhoea and vomiting may 
for a time thicken the blood by loss of water. Weiss shows an increase of 
the leucocytes and transitional leucocytes. 

Rachitis. — There is usually a reduction in the number of red corpuscles, 
a decrease in the percentage of haemoglobin, and an accompanying leuco- 
cytosis according to von Jaksch. 

8Un Diseases. — There is an increase in the number of eosinophiles. 
The cause of the same is unknown. 

Nervous Diseases.— In the functional disorders of childhood the blood 



THE BLOOD. 



729 



findings arc those of a moderate anaemia. Burr has found that the blood 
in chorea is not as a rule anaemic. In my own examinations (Fischer) the 
opposite result has been found, and I believe that in prolonged chorea a 
distinct leukocytosis can be found. 

The following table, prepared by Casper Sharpless, will assist in the 
differentiation of the blood : — 



Table No. 99. 



Disease. 


Leucocytosis. 


Lymphocytes. 


Neutrophiles. 


Red Cells. 


Hteruoglobin. 


Typhoid Fever 


Absent 


Relatively 
increased 


Decreased 


Decreased 


Proportionately 
decreased 


Typhoid with 
complications 


Present 




Increased 


Decreased 


Proportionately 
decreased 


Scarlet fever . 


Present 


Decreased 


Increased 


Decreased 


Proportionately 
decreased 


Measles. . . • 


Absent 






No change 


No change 


Small pox . . 


Marked on 
third day 




Increased 


Much de- 
creased 


Proportionately 
decreased 


Erysipelas . . 


Marked 




Increased 


Decreased 


Proportionately 
decreased 


Diphtheria . . 


Marked 


Earely 
increased 


Increased 


Slight de- 
crease 


Proportionately 
decreased 


Influenza . . . 


No change 






No change 


No change 


Typhus fever 


No change 






No change 


No change 


Follicular 
tonsillitis 


Moderate 






No change 




Acute rheu- 
matism . 


Moderate 




Increased 


Markedly 
decreased 


Markedly 
decreased 


Septicaemia . ■ 


Marked 




Increased 


Markedly 
decreased 


Proportionately 
decreased 


Abscess. . . . 


Marked 




Increased 


Decreased 


Proportionately 
decreased 


Meningitis . . 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Peritonitis . • 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Pericarditis . . 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Pleurisy . . 


Marked 




Increased 


Slightly 
decreased 


Proportionately 
decreased 


Malaria . . . 


Absent 


Relatively 
increased 


Decreased 


Decreased 


Proportionately 
decreased 


Pneumonia * . 
Appendicitis 


Marked 
Marked 


Decreased 


Increased 


Decreased 


Proportionately 
decreased 



1 In pneumonia there is a decrease of the eosinophiles and in scarlet fever an increase. 



730 DISEASES OF THE BLOOD. 

Blood Reaction of Pus. — The glycogenic reaction of the blood has fre- 
quently been described in literature. The first complete paper on this 
subject was published by Dr. M. Goldberger and Dr. Siegfried Weiss. 1 This 
diagnostic aid is of value when a questionable diagnosis exists. 

Through the courtesy of Dr. Knoepfelmacher, physician in charge of 
the Carolinen Children's Hospital, in Vienna, I saw the value of this re- 
action. In differentiating abdominal symptoms pointing to a typhoid fever 
or a suppurative appendicitis, we have an important diagnostic guide in 
using this blood reaction. 

Formula for Staining. 

Ifc Iodin sublim 7% grains 

Kal. iodati 22 grains 

Aquse destil 1 ounce, 1 scruple. 

Muc. acaciae, ad. consist, syruposam. 

The reaction is based on the following : — 

1. The polynuclear neutrophile leucocytes contain very many irregular 
granules of glycogen. These have a brownish color, sometimes a reddish- 
brown color. 

2. Mononuclear leucocytes usually contain large granules of glycogen. 
Besides the above, yellowish-brown stained extra cellular masses showing 
the glycogenic reaction are also found. 2 

Method of Taking a Blood Smear. — When fever exists and the diagnosis 
is obscure, the blood should be examined. A drop of blood can be withdrawn 
from the tip of the finger or the lobe of the ear. All rules of asepsis should 
be strictly applied. The needle can be passed through an alcohol flame or 
a Bunsen burner, the finger or ear quickly pricked, and the drop of blood 
thinly smeared over the cover glass. 

Differential Leucocyte Count. — When the polynuclear percentage is 70 
to 80, and there is a marked leukocytosis, we should suspect pus. This 
blood examination must be used to support the other symptoms indicating 
an empyema, an appendicitis or a mastoid, in fact any suppurative condition. 

Antibacterial Action of the Blood.— According to Halliburton 3 "the 
power of the blood to destroy bacteria was first discovered when an effort 
was made to grow various kinds of bacteria in it; the blood was believed 
to be a suitable soil for this purpose, but it was found to have the opposite 
effect in many instances. The chemical characters of the substances which 
kill the bacteria are not fully known. Evidence appears to favor the leuco- 
cytes as the origin of this bactericidal substance. These substances are 
called alexins, but the more usual name now applied to them is that of 

1 Wiener Klinische Wochenschrift, No. 25, 1897. 

2 An interesting contribution on this subject is found in the Transactions of the 
Section on Pediatrics of the American Medical Association, June, 1900, by Dr. 
Siegfried Weiss. 

3 Paper read before the British Association for the Advancement of Science. 



PLATE XIX 

lonoiMiiLiA. Pis Reaction of Blood. 




Coverglass Specimen of Blood in a Case of Suppurative Appendicitis. 
a, Polynuclear leucocytes; b, polynuclear leucocytes containing many irreg- 
ular granules of glycogen; c, extra-cellular iodine-stained masses, giving the 
reaction of glycogen. 




a, Pus corpuscles without iodine reaction; b, pus corpuscles, iodine reaction. 

(Original.) 



THE BLOOD. 731 

bacteriolysins. The bactericidal power of the blood is closely related to its 
alkalinity. Increase of alkalinity means increase of bactericidal power. 
Alkalinity is probably beneficial, because it favors those oxidative processes 
in the cells of the body which are so essential for the maintenance of healthy 
life. Normal blood possesses a certain amount of substances which are 
inimical to the life of bacteria. When a person gets run down there is a 
diminution in the bactericidal power of his blood. However, a perfectly 
healthy person has not an unlimited supply of bacteriolysin, and if the bac- 
teria are sufficiently numerous he will fall a victim to the disease which 
they produce. In the struggle he will form more and more bacteriolysin, 
and if he gets well it means that the bacteria are vanquished, and his blood 
remains rich in the particular bacteriolysin he has produced, and so will 
render him immune to further attacks from that particular species of bac- 
terium. Every bacterium seems to cause the development of a specific 
bacteriolysin. Immunity can more conveniently be produced gradually in 
animals, and this applies, not only to the bacteria, but also to the toxins 
they form/* 7 

The Blood in Fever. — There is a decided reduction in the number of 
red cells during fever. Whether the fever destroys the red cells or causes 
them to be unequally distributed in the body is the question. ^laragliano 
demonstrated a contraction of arterioles during the height of a febrile 
process, followed by dilatation during defervescence. He was able to verify 
these results by noting the effect of antipyretics (Ewing). 

Salkowski demonstrated an excess of potassium in the blood during 
fever, thus favoring the view that the red cells are destroyed. Senator, 
Von Jaksch, and others have shown that febrile processes are regularly 
marked by diminished alkalescence of the blood. When diphtheria anti- 
toxin is injected the alkalinity of the blood is increased for about twenty- 
four hours. 

The progressive loss of albumin is probably associated with every fever, 
but occurs in a marked degree when the fever is of an infectious origin. 
Diminished resistance of the red cells occurs in the majority of fevers and 
depends on a variety of factors. Variations in alkalinity are frequent and 
considerable in fever, but are not proportional to either the toxicity or to 
the height of the temperature (according to Ewing). 

The question is, why do almost all micro-organisms which are harmful 
to the body raise its temperature, and the suggestion has been made that the 
rise of temperature is a defensive mechanism, or. in other words, pyrexia 
is like phagocytosis or chemiotaxis, in some way harmful to the fever- 
producing micro-organisms or their toxins. It does not follow from 
this view that the higher the temperature of the body the better the 
prognosis, for the higher temperature might be taken to indicate that the 
dose of infection was very severe, and that, therefore, the body did all it 



732 DISEASES OF THE BLOOD. 

could to resist the invasion; nor, on the other hand, would it follow that 
if the temperature did not rise much, the dose of infection was slight, for 
it might be that the body was feeble and had but little power of raising 
its temperature, and therefore defending itself. 

Some years ago much was expected from the antipyretic drugs — anti- 
pyrin, acetanilid, and phenacetin; and if it could have been shown that 
they distinctly improved the condition of the fevered patient it would have 
been a strong argument against the view that pyrexia is a defensive mech- 
anism. 

When fever arises and a distinct diagnosis cannot be made, the child 
should be put on the expectant plan of treatment. This will consist in 
cleansing the gastro-intestinal tract, regulating the diet, and noting symp- 
toms as they arise. This is especially indicated when we believe the case 
to be, in the period of incubation, of an infectious disease. At such times 
the following recipe is a good antipyretic and will not depress the heart : — 

I£ Sweet spirits of niter 1 1 / 2 fluidrachms 

Citrate of potassium 30 grains 

Syrup of lemon 4 fluidrachms 

Aquae q. s. ad 2 fluid ounces 

A tea spoonful every three hours, for child 1 year old. 

It is generally believed, and in all probability correctly, that many 
cases of typhoid fever are benefited by cold sponging or by a cool bath. 
Many have hastily concluded that the bath does good because it lowers the 
temperature. But this is probably incorrect. In the first place we must 
remember that the cold sponging or bath does more than lower the tem- 
perature; it diminishes the delirium, the tremor, and the prostration. In 
any of these ways it would do good. But, further, Eoque and Weil claim 
to have shown that "in typhoid fever left to itself the toxic products manu- 
factured by the bacillus and organism are eliminated in part during the 
illness. The urotoxic -coefficient is double the normal, but this elimination 
is incomplete and is only completed during convalescence, for the hyper- 
toxicity continues for four or five weeks after the cessation of the fever. 
In typhoid treated by cold baths the elimination of toxic products is enor- 
mous during the illness. The urotoxic coefficient is five or six times the 
normal. The hypertoxicity diminishes as the general symptoms mend and 
as the temperature falls, so that when the period of pyrexia and convales- 
cence sets in the elimination of toxics has ceased." So we learn that it is 
by no means certain that in typhoid fever the benefit of cold baths is due 
to their antipyretic influence alone, but also to the elimination of toxins. 
We see that clinical medicine affords no evidence that antipyretics are useful 
in fever. 



CHAPTER II. 
DISEASES OF THE BLOOD. 

ANiEMIA. 

A deficiency in the number of red blood-cells or of the haemoglobin 
is known as anaemia. As a rule there are two distinct forms: first, con- 
genital; second, acquired. 

Congenital Form. — The foetus in utero is frequently anaemic owing to 
the inherited disease of its mother. Such diseases are blood disorders like 
syphilis, or where a general devitalization occurs, as seen in tuberculosis. 
If the mother while pregnant passes through a severe form of diphtheria, 
typhoid fever, or any other infectious disease, it may result in anaemia of 
her offspring. 

Malarial infection of the mother may also result in an anaemia of the 
baby. A severe haemorrhage due to an operation on the mother during the 
last period of her pregnancy may cause an anaemia of the baby. 

Acquired Form. — This form is due to either an infection of the baby 
or to toxic conditions acquired after birth and independent of the mother. 
Most cases of acquired anaemia seen by me are the direct result of mal- 
nutrition. I have referred in detail to this condition in the chapter on 
"Scurvy" and "Rachitis." 

Splenic Anemia. 

"It is evident that some of the cases now classified as pseudo-leukaemic 
anaemia belong to the group of the simple, severe, chronic anaemia of young 
children — splenic anaemia. Others, possibly, should be classed as leukaemia, 
but cases observed at Heubner's clinic indicate that although the blood 
presents the leukaemia formula, the affection may terminate in recovery. 
Alterations in the red corpuscles, especially the appearance of megaloblasts, 
should be considered pathologic in young children. The total number of 
leucocytes and the proportion of lymphocytes in this splenic anaemia are 
normally larger than usual. A polynuclear leucocytosis may be transient. 
The severe forms of anaemia in children are invariably accompanied by an 
enlargement of the spleen, but it may be enlarged also in mild anaemia, 
and also in its absence. The 26 cases described by Geissler and Japha dem- 
onstrate the existence of this disease of the blood in young children, espe- 
cially in those with rachitis. It ranges from a slight decrease in the 
haemoglobin and the number of the reds to the appearance of megaloblasts." 

(733) 



734 DISEASES OF THE BLOOD. 

Secondary Anemia. 

Causes. — Toxic influences frequently destroy the blood corpuscles and 
also the haemoglobin, hence anaemia results. When haemorrhage takes place 
then anaemia frequently follows. Malaria and whooping-cough seem to 
affect children more than adults. Other diseases, such as rheumatism and 
endocarditis, in fact, most of the acute infectious diseases, cause anaemia. 
Improper hygiene, and more frequently improper food, should not be over- 
looked as causative factors. 

Symptoms. — A pale white skin and waxy appearance of the nails is 
the usual clinical picture. Children do not appear bright. They take no 
interest in their surroundings, and do not wish to play. Loss of appetite 
and tendency to constipation frequently exist. 

Diagnosis. — This is usually determined by the condition of the blood. 

Prognosis. — The origin of the anaemia should be the guide- in deter- 
mining the outcome of this condition. Great care should be used in ven- 
turing an opinion, unless we are sure of the origin and can remove the cause 
of same. 

Treatment. — Fresh air, food (chiefly proteids), and restoratives, such 
as codliver-oil, lipanin, iron, Fowler's solution, and malt preparations, are 
indicated. Wine or champagne is sometimes valuable. ' - 

Pernicious Anemia. 

This rare condition is sometimes seen in children. 

Etiology. — It may follow simple anaemia so that it would appear as 
the result of a continuation of malnutrition. Many theories are offered. 
Tape-worm, syphilis, and rachitis are believed to be the factors causing this 
condition. 

Pathology. — Hunter first reported the presence of a deposit of iron in 
the hepatic cells. There is also an anaemia of the internal organs. Some- 
times capillary haemorrhages are seen in the various organs. Fatty degen- 
eration is also described as a frequent pathological finding. 

General Symptoms. — These are the same as previously described in the 
article on anaemia, although all symptoms are of a more severe type. Epi- 
staxis, in addition to local purpuric spots,, denotes the tendency to haemor- 
rhages. An interference of the return circulation to the heart is manifested 
by oedema of the feet and ankles. The urine contains neither albumin nor 
casts. 

Special Symptoms. — The blood will furnish the real means of diag- 
nosis. The haemoglobin may sometimes be as low as 20 to 30 per cent. 
The erythrocytes are reduced in number; 2,000,000 is a fair average red 
blood count in this condition, although Lenhartz 1 refers to a reduction of 

1 Lenhartz— "Clinical Microscopy," page 156. F. A. Davis Co., 1904. 



PLATE XX 




A. — Progressive Pernicious Anemia. The case ended fatally in six 
weeks; cause unknown; possibly in connection with typhoid fever. Ehrlich's 
triacid stain. Zeiss ocular 1, oil immersion V 12 . «, normal erythrocytes; 

b, megalocytes; c, microcytes; d, marked poikilocytosis; e, megaloblast; 
f, polynuclear neutrophilic leucocyte. (Lenhartz-Brooks.) 

B. — Lienal (Splenic) Leukaemia, a, normal erythrocyte; b. nucleated 
erythrocyte, nucleus eccentrically situated; c, polynuclear neutrophilic leuco- 
cytes; d, eosinophilic (myelo) cell. The eosinophilic cell at the top has 
been ruptured and the granula dispersed. Two small greenish-blue nuclei, 
perhaps small lymphocytes. (Lenhartz-Brooks.) 

V. — Lienal (Splenic) Leukemia. al, megaloblast; a, normal erythro- 
cyte; a2, megaloblast, with anaemic degeneration; b, polynuclear leucocytes; 

c, "marrow cells" (myelocytes); d, large lymphocyte. (Lenhartz-Brooks.) 

D. — Acute Leuk.emia. This picture is made from two different, rapidly 
fatal, clinically similar cases. The upper portion is stained with Ehrlich's 
stain with eosin-hematoxylin ; the lower portion is stained with the Plehn- 
Chenzinsky's stain. (Lenhartz-Brooks.) 



LEUKEMIA. 735 

erythrocytes as low as 400,000 to 800,000. There is also an enormous 
poikilocytosis. 

In this disease there is a greater reduction in the number of red blood 
cells (oligocythemia) than in any other disease. 

Leukaemia (Leukocytikemia) . 

In this condition we have a reduction of the red corpuscles and a cor- 
responding increase in the white blood cells. 

Cellular forms called lymphocytes not otherwise found in health are 
present in the blood. Yirchow calls this condition "white blood." Ehrlich 
calls it a leucocytosis of a chronic type. 

Etiology. — This is unknown. Some authors, Eoux and Lowit, describe 
asporozoa in the blood as well as in the leucocytes and in the spleen. Other 
writers believe that there is a predisposition in syphilitic and rachitic chil- 
dren. Unsanitary surroundings and injury to the spleen are decided etio- 
logical factors. 

The following classification is given by Ehrlich: — 

(a) Lymphatic forms. 

(b) Myelogenous and splenic forms. 

Lymphatic Form. — When the colorless corpuscles are as large as a 
normal erythrocyte then an involvement of the glandular system can be 
diagnosticated. 

Myelogenous and Splenic Forms. — If large cells appear then bone- 
marrow and the spleen evidently participate. When large mononucleated 
leucocytes are found then the bone-marrow is probably involved. If, in the 
field of the microscope, three to five or more cells filled with strongly re- 
fractive spheroid granules are found, the splenic involvement should be 
suspected. 

Pathology. — The lesions are confined to the bone-marrow, lymphatic 
glands, and spleen. The spleen is enormously enlarged, sometimes filling 
half of the abdominal cavity. Sometimes it is soft, and at other times very 
hard on palpation. It has a dark red color. In the lymphatic form any 
or all of the external glands of the body may be affected ; thus the cervical, 
maxillary, bronchial, mesenteric, or inguinal glands may be involved. 
There is a simple hyperplasia found in the glands. The liver io usually 
enlarged from an infiltration with lymphoid tissue. The lymphoid tissue 
in the tonsils and the thymus gland have the same changes. Haemorrhages 
are not infrequent. 

Symptoms and Diagnosis. — The disease is usually ushered in by a severe 
haemorrhage, after which profound anaemia and a general weakness are noted. 
The spleen is always enlarged and the lymphatic glands are palpable. The 
glands are movable, but never tender on palpation. The liver is usually 
enlarged. In the beginning there is little or no fever, although later in the 



736 DISEASES OF THE BLOOD. 

disease the temperature ma}' rise as high as 103° F. Sometimes from in- 
volvement of the liver there will be dropsy of the feet or a general anasarca. 
Haemorrhages from the nose, mouth, stomach, and bowels frequently com- 
plicate this condition. From the loss of blood fainting spells may occur. 

The Blood. — The characteristic feature is an increase in the number 
of leucocytes. The normal ratio between the red and white corpuscles varies 
between 1 to 500 and 1 to 1000. In leukaemia the ratio is so altered that 
we may have one colorless corpuscle to twenty, or even to five, red corpus- 
cles. Some authors report a ratio of one red to two white corpuscles. 

The eosinophil es are frequently increased many times their normal 
number. A characteristic feature is the presence of large and small mono- 
nuclear lymphocytes. Ehrlich describes a large mononuclear nutrophilic 
staining cell which normally exists in the bone-marrow, and is found in the 
myelogonous form of leukaemia. It is called the myelocyte. 

Treatment. — The nutrition of the child must be carefully considered. 
Albumin and the cereals should form the main portion of the food. All 
vegetables should be ordered. If the child can be taken out of doors, then 
the same should be insisted upon. Strict attention to hygienic details will 
greatly assist in modifying this condition. 

Medication. — Iron, arsenic, in the form of Fowler's solution, cod- 
liver-oil, and malt extracts should be given. If there is anorexia then 
strychnia or nux vomica should be given. 

pseudo-leuk^mic anemia of infancy (anemia infantum 
Pseudo-Leuk^mica) . 

Von Jaksch was the first to describe this disease in 1889. It is an 
infantile anaemia characterized by the following conditions : — 

1. There is a marked enlargement of the spleen. 

2. A slight enlargement of the liver and the lymph nodes. 

3. A marked reduction in the number of red corpuscles. 

It is usually a secondary anaemia rather than a primary disease. 

Etiology. — The disease is usually found in infants and children be- 
tween 6 months and 4 years of age. 

Monti and Berggrun collected 16 cases in 1892. Pickets, congenital 
syphilis, chronic intestinal catarrh, and tuberculosis were found in cases 
collected by Fischl. 

Pathological Anatomy. — The spleen is enlarged and rather firm. 
Histologically, the changes are those of simple hyperplasia of all elements, 
while the sinuses contain no excessive number of leucocytes. Baginsky 
found many eosinophile cells in the spleen. The changes in the viscera are 
described by Von Jaksch, Eppinger, Luzet, Baginsky, Audeoud, and 
Rotch. 



CHLOROSIS. 737 

The marrow, according to Luzet, is diffusely reddened and moist and 
shows evidence of excessive multiplication of the red cells. 

The Blood. — Leucocytosis is an important symptom. The white blood 
cells number between 20,000 and 50,000. Other cases (Baginsky) between 
40,000 and 122,000. 

According to Monti the proportion of white cells to the red may be 
as 1 to 100 or 1 to 15. 

Symptoms. — After a prolonged gastro-intestinal disease an infant will 
appear very anaemic. Fever is not usually present. When fever is pres- 
ent the cause of the same will usually be found other than in the spleen. 
Icterus is sometimes present. 

There is a decided loss of appetite and the bowels move sluggishly. 
The skin has a yellowish color and is intensely anaemic. The abdomen 
appears distended. The liver is slightly enlarged. The lymph glands are 
palpable. The spleen is very much enlarged and occupies the left hypo- 
chondrium, reaching at times to the crest of the ilium. 

Prognosis. — The prognosis is poor, although recovery does take place 
in some instances. A case of this kind seen by me has shown marked im- 
provement under anti-rachitic and restorative treatment. 

Treatment. — Tonic doses of iron, quinine, and strychnine served me 
well. Codliver-oil and the glycerophosphites of lime and soda are indi- 
cated. Phosphorus has been recommended by some. The bowels must be 
thoroughly cleansed, and the general peristalsis stimulated. Nux vomica, 
in 1 minim doses three times a day, when anorexia and gastric atony are 
present. Fresh air and general hygienic management, in addition to a 
supporting diet, will do more toward building up and restoring the system 
than all medication combined. 

Chlorosis. 

This is a primary anaemia which is usually found in girls at or about 
the period of menstruation. In our climate chlorosis can be seen between 
the twelfth and twentieth years of age. Blondes are more prone to this 
disease than brunettes. 

Etiology. — Sedentary occupation associated with lack of exercise, or 
poor hygienic surroundings, may induce this condition. Nervous girls 
susceptible to mental influences, such as fright or worry, are more prone 
to the development of this condition than robust, healthy girls. Auto- 
intoxication is certainly a factor, as I have frequently seen chlorosis in 
girls suffering with chronic constipation. 

Pathology. — Distinct pathological lesions cannot be attributed to this 
condition. In some cases ulcer of the stomach is associated, and this latter 
condition may be fatal. 

47 



738 DISEASES OF THE BLOOD. 

Symptoms. — The symptoms are those described in the chapter on 
"anaemia." The appetite is poor and such girls invariably crave for sour 
and spiced foods to stimulate the appetite. Constipation is most always 
present. Headache and other nervous symptoms are also present. Such 
girls are very emotional, and cry and laugh very easily. They are very 
sensitive. A venous murmur can usually be made out in the vessels of 
the neck. There is a blowing systolic murmur which can be heard over 
the heart in the mitral region and also in the region of the pulmonary 
artery. Venous thrombosis is most frequently seen in the femoral veins, 
and varicose veins are sometimes seen over the thighs and ankles. Men- 
struation is irregular and the flow is scanty or very profuse and sometimes 
painful. There is a decrease in the percentage of haemoglobin and also a 
decrease in the number of red corpuscles. The number of red cells may 
be reduced to 4,000,000. 

The spleen may be slightly enlarged, but on this symptom no reliance 
can be placed. A puffmess of the face or oedema of the ankles due to a 
sluggish return circulation is occasionally seen. 

The skin is of a greenish-yellow color. When localized areas of pain 
are complained of in the region of the stomach, then gastric ulcer should 
be suspected. In such cases an examination of the gastric contents should 
be made with the aid of a test-meal (see page 915, Part XII), to see whether 
or no hyperacidity is present. The eyes usually have a peculiar pearly 
sclerotic appearance. 

Diagnosis. — Chlorosis is met with in girls only at or about the period 
of menstruation. This is its characteristic diagnostic feature. Such chil- 
dren, as a rule, are fat and look well nourished. 

Prognosis. — This is always good, although the disease may last sev- 
eral years. If chlorosis is a forerunner of tuberculosis or gastric ulcer, 
then a fatal termination may occur. The outcome of a case depends on 
heroic restorative treatment. 

Treatment. — Hygienic Treatment: Eemove the child from its imme- 
diate surroundings, from the city to the country. If chlorosis occurs in a 
girl living at a boarding-school, in a convent, or in a girl working in a 
factory, the hygienic conditions demand : — 

1. To sleep in an airy room with the windows open at night. 

2. Discontinue working, or studying if at school, to procure mental 
rest. 

3. Change the entire mode of living, so that there is neither care nor 
worry for the chlorotic girl. 

Exercise. — Gentle exercise, walking, swimming, the lighter exercises of 
physical culture followed by a shower-bath and massage are valuable. Fric- 
tion with a coarse towel after the daily sponge bath is useful to stimulate 
the circulation. Beading or sewing at night must be forbidden. 



CHLOROSIS. 739 

Nutrition. — To stimulate metabolism nothing equals food. Proteids 
in the form of milk, meat, eggs, cereals, cream, butter, and cheese should 
be liberally given. All fresh fruits may be allowed. Regularity in feeding 
must be demanded, although a drink of milk, buttermilk, cocoa, or zoolak 
may be taken between meals. 

Medicinal Treatment. — Soluble preparations of iron, such as ovoferrin 
and neoferrum, may be given in teaspoonful doses after each meal. Arsenic 
in the form of Fowler's solution or arsenious acid may be combined with 
the iron. The arseniated haemaboloids have been tried by me with good 
result. Maltine with or without hypophosphites may be tried three times a 
day. Codliver-oil, morrholine, or lipanin may be tried in teaspoonful doses 
three times a day given after meals. The sun bath or the electric light 
bath may be tried in conjunction with the above-described treatment. 



CHAPTER III. 

ACUTE RHEUMATISM (POLYARTHRITIS). 

This disease is sometimes known as rheumatic fever, also as inflam- 
matory rheumatism. It is an acute, infectious, but non-contagious disease. 
The infection is characterized by an inflammation which localizes in the 
joints, and travels from joint to joint, evidently through the circulation. 
The most frequent complication is endocarditis. 

Etiology. — The specific factor is evidently a micro-organism. A great 
many observers have studied this subject, among them, Ley den, Sahli, 
Achalme, Eiva, Triboubet, Coyon, Singer, Jaccoud, and many others. A 
bacillus described as an anaerobic, with more or less motility, similar to the 
anthrax bacillus, has been described by Achalme. This bacillus, when in- 
jected into animals, has reproduced symptoms resembling rheumatism. 
Thus this observer believes he has found the specific agent causing this 
disease. 

Other causes have been described as the result of defective assimila- 
tion, which produces lactic acid or combinations of it. Another theory 
is the so-called nervous theory, in which the nerve centers are primarily 
affected by cold, and the local lesions are atrophic in character. 

This nervous disturbance brings about hurtful metabolism, so that the 
nitrogenous products, instead of being converted into urea, are transformed 
into uric acid and other poisonous products which cause these symptoms. 

Whether or not heredity bears any relationship to the cause of this 
disease may be considered by the fact that in two-thirds of the cases, dis- 
eases of a similar type can be traced to the ancestors. Gouty parents 
will usually have rheumatic children. The disease is very common in 
children, and has also been observed in nurslings. 

Eheumatism occurs more often in the spring of the year. When the 
disease has commenced, it usually lays the foundation for future attacks; 
in other words, one attack of rheumatism predisposes to future attacks of 
the disease. 

The tonsils have frequently been looked upon as the seat of entrance 
of this disease; thus acute tonsillitis has frequently been followed by acute 
articular rheumatism. In the same manner endocarditis has frequently 
followed an attack of tonsillitis. It is therefore safe to assume that the 
specific entrance of an infection can originate in a diseased tonsil. 

Packard has described a series of cases of endocardial inflammation 
(740) 



ACUTE RHEUMATISM. 741 

following tonsillitis. He regards a serous inflammation as due to the germs 
or other toxins entering the circulation through inflamed tonsils. 

Bacteriology. — Triboulet and Coyon 1 give the results of their bac- 
teriologic examinations in 11 cases of acute articular rheumatism. They 
discovered in all these cases a diplococcus or diplobacillus which they state 
cannot be well described as to its cultural peculiarities, as its growth is so 
irregular. 

The organism exhibits great plesiomorphism and resembles most closely 
in character the diplococcus pneumonia?, but differs from it in that it can 
be kept alive for a considerable length of time, and that it is not patho- 
genic for mice. The organism is extremely pathogenic for rabbits, and 
the authors give a detailed account of its effects on a rabbit. The animal 
died twenty days after intravenous inoculation. Death was due to heart 
failure resulting from an absolute mitral insufficiency. During life there 
was an oscillatory temperature. The autopsy showed fresh pleuritis and 
pericarditis, and an acute vegetative endocarditis with tremendous masses 
of vegetations on the mitral valve. The vegetations microscopically showed 
many diplobacilli similar to those originally inoculated, and cultures from 
the organs also showed it. Other rabbits inoculated with smaller doses from 
other cases show r ed irregular fever, disturbances of the heart, and pleurisy, 
but did not die. 

Symptoms. — The symptoms are entirely different from those met with 
in adults. The fever is not so high, usually between 100° and 102° F. 
The swelling of the joints is moderate, and there is not the redness and 
inflammation visible to the eye as we see it in adults. The pains are not 
severe in all cases, and there are less joints involved as a rule than we 
find in adults. We therefore meet with a great many cases of rheumatism 
that walk around suffering slight pains. Sometimes the lower extremities 
are affected, at other times the disease is limited to the upper extremities. 
A child may walk apparently lame or an infant may cry when put on its 
feet. Jacobi years ago directed the attention of the profession to the 
necessity of carefully watching every case of so-called "growing pains." 
He believed, and correctly so, that the majority of these cases were in 
reality rheumatism. The most frequent symptoms are vomiting, fever, gen- 
eral malaise, anorexia, in addition to multiple arthropathy. 

Rheumatism a Sequela to Tonsillitis. — That rheumatism is irequently 
a sequel to tonsillitis has been noted by many observers. Packard, of Phila- 
delphia, has reported a series of cases in which the throat was first affected 
and later heart disease w r as distinctly manifested. Emil Mayer, of New 
York City, has also reported a series of cases in which the tonsils were the 



1 Comptes Rendus de la Societe de Biologie, February 4, 1898, 



742 DISEASES OF THE BLOOD. 

portals of infection. This is certainly not a theory when we study the 
primary infection and follow it up with its secondary result. 

Sir Willoughby Wade 1 says, in relationship between tonsillitis and 
rheumatic fever, he believes that tonsillitis is a primary infective disease 
of the lacunae; rheumatic fever a secondary disease arising from the 
absorption of microbes or their products into the system. Knowing this 
to be a factor, it would only seem proper to treat every tonsillitis as vigor- 
ously as possible. 

Acute Contagious Articular Rheumatism. — Gr. B. Allari reports 3 
cases which were characterized by contagiousness and at the beginning of 
the disorder with angina of the throat. In the fourth case the angina re- 
appeared with every reappearance of exacerbation of the articular symptoms. 
Bacteriological investigations of the exudate on the tonsils showed in each 
case a streptodiplococcus which was almost identical in structure and be- 
havior with that found by Mayer in the same affection. Animals inoculated 
with this micro-organism developed lesions in the joints. 

Subcutaneous Tendinous Nodules. — Barlow and Warner described this 
manifestation of rheumatism in 1881 as oval semi-transparent fibrous bodies 
like boiled sago grains. They are most frequently met with at the back of 
the elbow, over the malleoli, and at the margin of the patella. Occasionally 
on the extensior tendons of the hands, fingers, and toes, or over the spinous 
processes of the vertebrae. They are composed of fibrin, cells, and fibrous 
tissue. They vary in size from a pin-head to a small bean, though some- 
times being as large as an almond. They may remain for months, although 
they frequently disappear in a few weeks. Cheadle states that they can be 
seen if the skin is tightly drawn. Cheadle has also shown the intimate rela- 
tionship between erythema and rheumatism. 

Purpura. — This is frequently met with in the course of rheumatism. 
It is a rash of a deep purplish hue and is most probably a result of rheu- 
matism. 

Complications. — The most frequent form of complication is endocar- 
ditis. Fully 75 per cent, of my cases met with in a large outdoor practice 
showed this form of complication. This complication has frequently been 
the first symptom that led to the discovery that our patient had rheuma- 
tism. 

Pericarditis is rarely seen in children under 7 years of age. It is 
usually associated with endocarditis. 

Pleurisy, peritonitis, or meningitis may complicate rheumatism. 
Chorea frequently associates itself with rheumatism, so that a great many 
authors believe that there is an intimate relationship between rheumatism 
and chorea. 



1 British Medical Journal, 1898. 



ACUTE RHEUMATISM. 743 

Holt states that in a series of cases of chorea observed by him, 50 
per cent, gave evidence of the rheumatic diathesis. 

Prognosis and Course. — The course of rheumatism depends on the 
treatment. Pains in the joints should never be regarded as a trivial 
matter. How frequently do we see a child suffering with what the mother 
calls "growing pains," and a few weeks or months later we note shortness 
of breath due to heart trouble, usually endocarditis. It is better to put a 
child to bed than to run risks of such a serious complication. The prog- 
nosis depends on the care bestowed, although we know that this disease has 
a tendency to assume a chronic course. However, a case with proper treat- 
ment should recover entirely. The inflammatory stage lasts from ten days 
to two weeks. Cases of inflammatory rheumatism complicating scarlet 
fever or diphtheria lasting between three and eight weeks have been seen 
by me during my hospital service. 

Eheumatism in children assumes the course of a general infectious 
malady. The intensity of cardiac complications cannot be approximated 
by the intensity or mildness of articular manifestations. Many authorities 
state that the percentage of cardiac complications is between 81 and 87 
per cent. 

Lethal termination will frequently show pericarditis, hence the im- 
portant deduction is to prevent such complications, if possible, by proper 
prophylactic treatment. 

Treatment.— The first thing to do is to put the child in bed. The 
patient should be kept in bed until every particle of pain and fever is gone. 

1. When the disease is localized we can treat the same and try to 
destroy as much of the pathogenic infection as possible. 

2. The important point would be to restore the subnormal condition at 
the time of the invasion of these infective germs, and prevent thereby the 
absorption of the toxins generated from these micro-organisms. 

3. Watch for possible complications. While it is true that we can 
limit by local treatment the spread of active infective processes, on the 
other hand, when the body is weakened from anaemia, or from other de- 
pressing influences, this infection will spread in spite of the most vigorous 
local treatment. 

Kest must be enjoined, more so in children with this disease than in 
most other diseases. We must aim to have the most perfect physiological 
repose. In this way we have the longest interval between the systoles and 
we keep down the blood pressure. 

Prophylactic Treatment. — In trying to prevent rheumatism the hy- 
giene of the skin requires careful attention. The body should be properly 
protected, due allowance being made for sudden changes in the weather. 
Too much clothing means overheating. Perspiration induced thereby in- 
vites this disease when the surface is suddenly chilled. Overheated apart- 



744 DISEASES OF THE BLOOD. 

ments render children peculiarly susceptible to this disease. Proper ven- 
tilation, without incurring any draught, is urgently demanded. Cool or 
tepid bathing or sponging has a very good effect on the skin. Unneces- 
sary and useless hardening of children, by exposing them to cold baths in 
cold rooms, without proper protection, will certainly invite this disease.' 

Dietetic Treatment. — Milk and milk foods; cereals and fruits, espe- 
cially acid fruits ; broths and all soups made from meat are indicated. For 
thirst, buttermilk, and all fermented milks, seltzer and milk, alkaline waters, 
lithia, apollinaris, white rock, lemonade, and orangeade. 

Medicinal Treatment. — The alkaline treatment known as Fuller's 
method has been abandoned many years ago. The first thing to do is to 
cleanse the gastro-intestinal tract. A wineglassful or more, depending on 
the age of the child, of citrate of magnesia, repeated every two hours, until 
its effect is produced. Ehubarb and soda, 5 to 10-grain doses, or calomel, 
is valuable. Salicylate of soda, 3 grains every three hours, for a child 3 
years old. Older children in proportion. This treatment should be con- 
tinued two or three days, if the drug is well borne : — 

Ifc Natr. salicylat 1 drachm 

Elix. lactopeptin 2 ounces 

M. Sig.: One drachm every three hours may be given. 

Salol or salophen, in doses of 2 to 5 grains, is indicated. Aspirin is 
a valuable remedy in doses of 3 to 10 grains given every three hours. 
Cotton saturated with the oil of wintergreen applied over the affected 
joints, the whole covered with oil silk, is recommended. 

Fever. — Fever requires the same treatment in this disease as in all 
others. Cold sponging of the surface will do good. 

Restorative Treatment. — The profound anasmia caused by this disease 
is an indication for early restorative treatment. We should therefore aid 
nutrition by giving cream, butter, and, if tolerated, codliver-oil, with or 
without malt. Iron and iodide of sodium are good restoratives. Fellows' 
syrup of the hypophosphites may be tried. The application of leeches, 
blisters, or sinapisms sometimes does good. Ice-bags applied over inflamed 
joints will reduce swelling, remove heat, and have a very soothing effect. 

An ice-bag applied over the heart if endocarditis complicates has served 
me quite well in some cases. For the management of heart complications, 
see chapter on "Heart Diseases." 

It is vital to stimulate the action of the kidneys. For this reason I 
have previously mentioned the alkaline mineral waters. If a diuretic is 
indicated none is better than Basham's mixture. See formula in chapter 
on "Scarlet Fever," page 667. 

The following ointment is useful applied on gauze to the affected 
joint; — • 



MUSCULAR RHEUMATISM. 745 

IJ Methyl salicylate 1 part 

Vaseline 10 parts 

Mix. 

Apply morning and evening. 

Warm Bathing. — By adding sulphur in the form of kalium sulphuret, 
about 1 ounce to an infant's bath-tub of water, and bathing the affected 
joints at a temperature of 95° to 100° F., is sometimes very grateful and 
well borne. It is not advisable to make sudden changes in the local treat- 
ment. If ice-bags have been used and are well borne, they should be 
continued. Sulphur baths, so also pine-needle baths, are very grateful in 
the evening, and sometimes promote sleep. When pains are very severe, 
full doses of codeine or chloralamid may be given. It is seldom that so 
much truth is contained in a single sentence as in the following from 
Cheadle: "The various manifestations of rheumatism massed together in 
the case of adults tend to become isolated in the case of children, so that 
the whole phenomena are distributed over years instead of weeks or months, 
and the history of a rheumatism may be the history of a whole childhood. 



9) 



Muscular Eheumatism (Myalgia). 

This painful condition is rarely seen in children. It is characterized 
by pain when the muscles affected are brought into play. When the dis- 
ease affects the muscles of the neck it is called acute torticollis. When the 
intercostal muscles are affected it is called pleurodynia. When the lumbar 
muscles are affected it is called lumbago. Peculiar contractions of the 
muscles frequently follow persistent muscular rheumatism and sometimes 
cause permanent deformity (see chapter on "Torticollis"). Infants so 
affected usually cry when the group of muscles involved are moved. There 
is no fever present. 

R. K., 16 years old, was attacked with a severe tonsillitis. The cervical glands 
were enlarged and tender on palpation. Creosote inhalations and unguentum Crede 
rubbed into the glands of the neck relieved this condition. Two days later after 
going out into the street she had violent muscular pains involving the back, groin, 
and muscles of the thigh. It was a distinct lumbago and a general myalgia. There 
was also a painful sciatica. With the aid of massage and the internal administra- 
tion of 5 grains (0.3) salophen every four hours these pains gradually subsided. 
After these pains left there were pains involving the intercostal muscles, so that we 
had a lumbago followed by pleurodynia. Rest in bed, warmth, and massage relieved 
this condition permanently. 

Treatment. — Local treatment consisting of massage aided by gentle 
faradic electricity is very useful. Warm, moist fomentations, such as flax- 
seed meal poultices, are very soothing and seem to do good. The internal 
administration of salicylate of soda has not seemed to benefit my cases. 
Codeine in y i0 to 1 / J5 -grain doses, repeated every two or three hours, can 



746 DISEASES OF THE BLOOD. 

be given until the pain ceases. In some cases chloral hydrate combined 
with bromide of sodium will afford relief. Eubbing the affected muscles 
with ol. hyoscyamus seems to relieve. 

Torticollis (Wry-neck). 

This condition is caused by the spasm of one sterno-cleido-mastoid 
muscle. Sometimes there may be a spasm of the posterior cervical muscle, 
including the trapezius. 

Etiology. — Congenital torticollis is a rare condition. When it is 
present it is due, according to Whitman, to a constrained condition in 
utero. 

More common than the congenital condition is the acquired torticollis. 
The following is Whitman's classification: — 

1. The acute. 2. The chronic. 

Acute torticollis (traumatic torticollis) may be divided into three 
classes : — 

(a) "Stiff neck," due to "cold" or to rheumatism. 

(b) Distortion caused by strain or other injuries. 

(c) Distortion due to irritation of the peripheral nerves as following 
"sore throat," or secondary, to enlarged or suppurating cervical glands, and 
the like ("reflex torticollis"'). 

The ordinary stiff-neck is of but slight importance. The traumatic 
wry-neck is efficiently treated by support. Keflex torticollis is by far the 
most important of the forms of acute torticollis, and it is the usual cause 
of persistent distortion. 

Chronic Torticollis. — From the clinical standpoint, both the congenital 
and the reflex torticollis, after the acute stage has passed, are forms of 
chronic torticollis; the class includes also those forms in which the onset 
has not been accompanied by pain. 

Rachitic torticollis, usually a postural or compensatory distortion 
caused by deformity of the spine. 

Ocular torticollis, caused by defective eyesight. 

Psychical torticollis, a functional or hysterical deformity. 

Spasmodic torticollis, a convulsive tic — rather a form of nervous dis- 
ease than a simple deformity. 

Any irritation of the spinal accessory nerve or its branches may bring 
on this spasm. Whitman 1 gives the following statistics of 264 cases ex- 
tending over nineteen years, torticollis from Potfs disease not being in- 
cluded : Males, 109 ; females, 155 ; congenital. 32 ; under 2 years. 33 : 
from 2 to 10 years, 153; over 10 years, 46; acute (less than two months' 



1 Report for Hospital of Ruptured and Crippled, Xew York. 



PURIH 747 

duration}. TT; chronic, 60, of which number 22 had lasted over two 
or longer. 

Holt believes that an enlarged cervical lymph gland irritating the 
spinal accessory nerve can bring on this spasm. He also mentions malaria 
as a cause. I have observed similar conditions. In several of my 
the spasm was present when malarial infection existed, and subsided when 
quinine was given. Torticollis has also been observed by me after the 
sudden chilling of the body. 

Symptoms. — The head is drawn to the affected side. If the trapezius 
is affected there is slight rotation of the head, but if the trapezius is not 
affected the head is rotated toward the healthy side. 

A child 6 vears old was taken on an open ear. She was in a healthy condition, 
appetite good, bowels regular, apparently nothing wrong. She complained of being 
cold and on the following day had a wry-neck. Salicylate of soda, in 5-grain doses 
three times a day. and massage of the sterno-cleido-mastoid with spirits of camphor 
seemed to relieve the pain. The best result was obtained by the nse of a mild 
faradic current. The condition lasted about nine days. The child was discharged 
cured. 

The above case illustrates the form commonly described as rheuma- 
tism or "''rheumatic tortiecl 

Treatment. — Medicinal and Local: Early treatment means success. 
Delayed treatment means disappointment in most instances. When specific 
causes exist, such as malaria or rheumatism, they should be treated by 
specific remedies. In every case warmth, as flaxseed poulticing and mas- 
sage, will do good. Sometimes the application of iodine oxer the affected 
muscles will do good. 

S rgical Treatment. — Lorenz describes the fine results attained by sub- 
cutaneous intentional rupture of the sterno-cleido-mastoid muscle to cure 
obstinate wry-neck in children. The subject lies with a hard cushion under 
the shoulders, the head and neck unsupported. The shoulder is drawn down 
at the same time and it is thus possible to tear the muscle by gradual de- 
hiscence, followed by over-correction. Parents accept this operation much 
more readily than when the knife is used, and the dehiscent fibers heal 
under the intact skin with little if any cicatricial formation. The cure has 
been ideal and permanent in all Li - 

Purpura. 

Haemorrhages into the skin or mucous membrane are designated as 
purpura. When small they are called petechial : when large they are called 
ecchymoses. Purpura is frequently associated with the infectious di~ 

Martha B.. 7 years old. was brought to the Willard Parker Hospital August 31. 
1903. She had been ill two days before admission. The diagnosis of nasal diphtheria 
was made. On admission the pulse was 158. Two days later it dropped to 90. and 
on the third day the pulse-rate sank from 96 to 66. A general purpura was notice- 



748 



DISEASES OF THE BLOOD. 



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able. There were bluish discolorations of the skin visible on the extremities. Dr. 
Burckhalter, the resident physician, called my attention to a hsematuria. The case 
ended fatally. 

Purpura Hemorrhagica (Morbus 
Maculosus Werlhofii.) 

This is the most severe form of 
purpura. The lesions are a series of 
haemorrhages confined to the mucous 
membrane and skin. On the skin 
purpuric spots are seen which de- 
note haemorrhages. These haemor- 
rhages are seen in the lower and up- 
per extremities ; also on the face and 
abdomen. The conjunctival mu- 
cous membrane shows ecchymotic 
areas. The gums bleed easily and 
there are haemorrhagic areas on the 
soft and hard palate. Haematuria 
and haemoptysis are sometimes seen. 
Diagnosis. — The only disease 
that might be taken for purpura is 
scurvy, but the general history of 
the case associated with malnutri- 
tion will clear up any doubt. 
Treatment. — Best, iron, small doses of ergot and hydrastis internally, 

lemons, oranges, and a nutritious diet. Aromatic sulphuric acid in 5-drop 

doses, several times a day, should be remembered. 

Purpura Rheumatica (Peliosis Rheumatica: Schonxein's Disease). 

The association of haemorrhages with affections of the joints charac- 
terizes this disease. It has frequently been noted that there is tenderness 
in the joints during the course of simple purpura. But the more pro- 
nounced form of fever, in conjunction with swellings and tenderness of 
the joints, plus the characteristic appearance of the subcutaneous haemor- 
rhages appearing in purpuric spots, differentiate peliosis from simple pur- 
pura. 

Associated with this rheumatic affection we frequently have extravasa- 
tions of blood and serous effusions into the joints, giving a decided fluc- 
tuating feeling. One very important point is the fact that cardiac lesions 
do not complicate this condition. Cases of this kind have frequently been 
reported, and Baginsky lays stress on the non-existence of heart lesions 
in this affection. 



Fig. 234. — Malignant Purpura Compli- 
cating Nasal Diphtheria. General sepsis. 
Toxic Nephritis, meningitis, myocarditis. 
Note pulse. Fatal. (Original.) 



PURPURA. 749 

The following case came under my observation 1 : — 

A child, George P., about 9 years old, was attacked with pains in his feet and 
cried when attempting to walk. He had had some very violent exercise during the 
four or five weeks preceding this attack by riding a bicycle as much as four and five 
hours daily. The mother stated to me that he had frequently complained of joint 
pains, but she attributed them to "growing." She noted, however, that after bicycle 
riding the boy's pain was much more intense. His general condition was otherwise 
healthy. The examination gave me the following status: — 

A very well nourished boy: muscular and adipose tissues quite well developed, 
and very tall for his age. His weight was 84 pounds. The examination of the 
thorax showed both heart and lungs normal; no cough; heart sounds regular, 
strong; pulse, 96. The temperature was 100.2 in the rectum, and respiration 36. 
The tongue was slightly coated; appetite good; bowels always inclined to constipa- 
tion; but recently since riding the bicycle, very much improved. Intellect free, and 
the boy is mentally well developed. 

The examination of the joints showed severe tenderness and swelling in both 
knees and ankles; slight pain on palpating or rotating the hip joint. The most 
marked tenderness and swelling was found at the knee joints. The upper extremi- 
ties — shoulder, elbow and wrist — were perfectly normal, as far as palpation and 
inspection could demonstrate. The eruption on the skin was of a purplish or bluish 
color, and looked like a distinct subcutaneous haemorrhage. It was confined to the 
lower extremities, covering almost completely the inner portions of both thighs, the 
ankles, and more especially the calves of both legs. The spots were very irregular in 
outline, in some places confluent, resembling more particularly the eruption of 
morbilli. 

The child was put to bed, the joints were rendered immobile by applying woolen 
roller bandages over them, and locally over each joint some salicylic collodion, 10 per 
cent., was applied with a camePs-hair brush. 

The main point in the treatment which I laid stress upon was to have absolute 
rest, and it was for this reason that I put the child to bed, that I painted salicylic 
collodion, and that I put a roller (flannel) bandage on the legs and covered both 
limbs from the toes to the hip joint. Internally I gave ergo tine, Vbo grain every four 
hours, besides 15 drops of tinct. ferri acet. aeth. in water after each meal, three 
times a day. The spots gradually changed from a deep bluish color to a brown; 
then after ten days to a light yellowish color, and after twenty-seven days they could 
scarcely be seen with the naked eye. 

This case has a very interesting clinical history. The question that arose in 
my mind was: Did the violent exercise on the bicycle cause the inflammation of 
the joints and possibly also the subcutaneous haemorrhages ? On looking over the 
previous history of the child, I found that he had been well nourished, breast-fed 
until eleven months, and then weaned; commenced walking at 1 year, and talking at 
same age. Dentition began at seven months, and when eight months had two lower 
and two upper incisors"; the child had seven teeth at eleven months, at time of wean- 
ing. 

There is no sign of rickets, although there is a large belly, rather pendulous, 
and the previous history of constipation. The ribs are normal, the long bones well 
developed; spine and thorax as good as desired. I could obtain no data concerning 
time of closure of fontanels. There is no history of haemophilia; no previous bleed- 
ing; no epistaxis; no haemoptysis; both parents of the child living, and both 



1 Pediatrics, vol. ix, No. 10, 1900. 



750 DISEASES OF THE BLOOD. 

healthy. The child has had measles, complicated with bronchitis, when 3 years old, 
lasting in all about one month. No disease previous to this; no summer complaint, 
and nothing since that time. 

There is no evidence of scurvy; teeth are well developed, perfectly normal;- the 
gums are healthy. The mother had two other children — one now nursing and one 
4 7 a years old. She has had no miscarriages ; no reason to suspect lues. 

I believe the etiological factor in this case was the traumatic element, namely, 
the violent exercise causing both the haemorrhages and the inflammatory affection of 
the joints. 

Henoch's Purpura. 

Hasmorrhagic areas confined to the abdomen and lower extremities 
are sometimes seen. There is also vomiting and abdominal symptoms, 
such as diarrhoea (bloody stools) and colicky pains. There is marked 
distension of the abdomen and pains in the joints. This condition 
resembles that which has already been described in the article on "Purpura 
Rheumatica." 

LlTH^MIA (LlTHURIA). 

Haig and Eachford have given us a very clear conception of this con- 
dition, which is simply an excess of uric (lithic) acid in the blood. Haig 
designates this condition as uricacidaemia. Other writers call it lithuria. 
Eachford calls this "leucomain poisoning." 

Etiology. — When this condition is met with in children, we can usually 
look to the lithaemic ancestors for the origin of the disease. Imprudent 
diet, such as excess of proteids, may be a factor. Sedentary life and lack 
of proper metabolism invite this condition. The alloxuric bodies are ex- 
creted by the skin, kidneys, and intestinal canal. These bodies are removed 
by the kidney cells from the blood into the urine. When they are in excess 
they must, therefore, have been present in solution in the blood before their 
elimination. 

The presence of uric or lithic acid, xanthin, hypoxanthin, hetero- 
xanthin, and paroxanthin are the factors causing this trouble. We are 
still in the dark concerning the manner in which these bodies act. 

If the kidneys are diseased these bodies are retained and the skin is 
called upon to do the work which the kidneys fail to do. Thus it is that 
hot baths which promote diaphoresis eliminate through the skin, in addi- 
tion to stimulating the action of the kidneys. 

Symptoms. — The new-born lithaemic infant frequently eliminates an 
excess of urates during the first few days of life. In such infants crystals 
of uric acid may be precipitated into the tubules of the pyramids of the 
kidney. Jacobi says that these uric acid infarctions may subsequently be 
washed out of the tubules and serve as the nuclei of urinary calculi. 

Nocturnal incontinence is frequently a symptom of lithaemia. True 



PLATE XXI 




Henoch's Purpura. Xote ecchymotie spots on lower 
extremities. ( Origins 1. ) 









LTTH/EMIA. 












751 


arthritic 


gout 


resulting Prom 


unit ie 


deposits 


in 


the 


tissues 


aboi 


it the 


joints 


is very rare in 


childhood. 



















Fever, crying while the child passes urine, scanty urine which usually 
deposits a reddish sand ou the diaper, and irritation of the external genitals 
are the symptoms which appear at the time of urination. The urine is 
very acid and we speak of this condition as u a uric acid form of lithsemia." 
Sometimes there are gastro-enteric manifestations, such as vomiting, head- 
ache, gastric pain, convulsions, a sickening odor of the breath, and consti- 
pation. These gastric symptoms bear no relation to improper diet. They 
are usually met with in children who are carefully guarded as to the diet. 
Such children are extremely nervous and irritable. Eczema is a very com- 
mon manifestation of this condition. Unless a proper understanding of 
this condition exists it will persist and be difficult to relieve. 

The urine in lithcemia is high colored; the specific gravity increased. 
On standing, there is a sediment of red sand (urates). If the urine is 
examined immediately after a paroxysm then the poisonous xanthin bodies 
previously mentioned may be found present. Transient albuminuria is 
occasionally met with. 

Treatment. — The diet is the most important part of the treatment. 
Cereals must be given; beef juice, soups, broths, and fruits. No alcoholics 
should be given; in fact, all rich and heavy articles of food must be ex- 
cluded. Meat must be given sparingly. Salads and gravies are objection- 
able. Infants require massage. This passive form of exercise will stim- 
ulate the circulation. If children are old enough to exercise, then exercise 
should form an important part of the treatment. 

Drug Treatment. — Calomel should always be given in the commence- 
ment of the treatment. We must aid in keeping the bowels loose during 
the whole course of treatment. 

Salicylate of soda and salol are useful eliminatives. Phosphate of 
sodium and benzoate, especially if eczema exists, are valuable. Alkaline 
waters, such as white rock and apollinaris, may be given ad libitum. 
The Carlsbad waters have the same eliminative effect. Dilute hydrochloric 
acid or dilute phosphoric acid in 3 to 5-drop doses before meals is es- 
pecially indicated when severe headache and gastric symptoms exist. 
Urotropin in 2-grain doses may be given in tablet form. 

HEMOPHILIA. 

This is usually an inherited condition. It is characterized by a ten- 
dency to bleed, hence the term "bleeder'' is applied to this class of cases. 
Whole families are found in which this tendency to bleed exists. 

Pathology. — The walls of the blood-vessels show no alteration, either 
macroscopically or microscopically. "The swelling of the joints is due to 
haemorrhages into the articulations and into the surrounding tissues. The 



752 DISEASES OF THE BLOOD. 

tissues are blanched from loss of blood." The surface of the body shows 
petechia? or bruised patches. 

Symptoms. — The appearance of the child does not always disclose the 
tendency to bleed. It is only when an operation is performed or an in- 
jury exists that alarming and frequently fatal haemorrhages are seen. 
Epistaxis is the most common symptom noted. Swelling of the joints 
resembling rheumatism is frequently seen. The bleeding takes place 
from the capillaries, most often an oozing which may continue for weeks. 
The subjects of haemophilia are sensitive to cold. 

In the chapter on "Syphilis" I have already described a case of bleed- 
ing in which the lesions of syphilis were present. 

Annie G., 13 years old, was breast-fed in infancy. She had diphtheria when 
1 year old. Had pertussis when 2 years old, which lasted nine weeks. HaB had 
pneumonia twice. No history of rheumatism given and has had no other infectious 
disease. 

History of Bleeding. — Has always been troubled with haemorrhages. The nose 
bleeds at the slightest provocation. Blood spitting is quite common. The slightest 
irritation of the bowels with looseness is associated with blood in the stools. Large 
varicose veins are found .over the legs. There are a, number of scattered naevi. Not 
infrequently the veins of the legs bleed daily for a period of twenty or thirty days. 

The Heart. — There is a loud systolic murmur heard in front and behind, and 
transmitted to the side. This endocarditis is a sequela to the attack of diphtheria. 
The child's weight when seen by me was 67 pounds. Stypticin seemed to do more 
good than ergot internally. Hydrastinine hydrochlorate, Ve grain three times a day, 
seemed to check the bleeding during another attack. When last seen by me the child 
was developing fairly well. 

Prognosis. — This depends on the frequency of the haemorrhages and 
the child's general condition. In 152 cases reported by G-randidier more 
than one-half died before completing the seventh year, and only nineteen 
attained majority. 1 

Treatment. — All operations, no matter how slight, should be avoided 
if possible. Even the extraction of a tooth must be seriously considered, 
owing to the danger of bleeding. 

The diet should consist principally of vegetables and fruits. When 
bleeding occurs, immediate treatment, consisting of ice and Monsell's solu- 
tion, should be used locally. Internally, gallic acid and hydrastine, 
V 8 grain, repeated every three or four hours. If intestinal haemorrhage 
exists, colon flushings of tepid water, temperature of 80° F., containing 
1 drachm of alum to 1 pint of water, may be tried. Ice water is also 
recommended for the same purpose. 

The injection of 15 to 30 cubic centimeters of sterile horse serum is an 
excellent haemostatic. In the case of a "bleeder," recently seen by me in 
the Babies' Wards of the Sydenham Hospital, one injection of horse serum 
controlled the haemorrhage due to a paracentesis, after all local means failed. 

i See article in "Starr's Text-book." 



CHAPTER IV. 
DISEASES OF THE GLANDS OR LYMPH NODES. 

The Thymus Gland. 

This long tabulated gland is similar in structure to the salivary glands. 
It lies in the anterior mediastinum, immediately behind the manubrium 
of the sternum. The thymus reaches its full development during the second 
year, after which it gradually disappears. The function of the thymus is 
still a question, although it is believed, to have a function similar to the 
spleen. Sudden death has frequently been attributed to an enlarged thy- 
mus. Tuberculosis involving the thymus gland is occasionally seen in cur- 
rent literature. 

Status Lymphaticus. 

This condition is found in rachitic children, and is of especial interest 
because of the enlarged glands at the angle of the jaw in addition to the 
adenoids in the vault of the pharynx, and enlargement of the lingual tonsil. 

The cervical, bronchial, axillary, or the inguinal glands are enlarged. 
There is also a tendency to swelling of the parts. Enlarged lymph nodes 
at the angle of the jaw and hyperplasia of the connective tissue of the nose 
and pharynx are seen. 

The thymus gland is very much swollen, and this is believed to be the 
cause of sudden death in many cases. 

Escherich believes that the pathological condition of the thymus gland 
causes a form of acute intoxication resulting in cardiac syncope and paral- 
ysis. This condition must not be confounded with scrofulosis. 

Escherich has reported a case in which laryngeal spasm occurred thirty 
times a day. In such cases the danger of asphyxia should be borne in mind. 
The condition is of importance because of the danger involved during the 
administration of an anaesthetic. 

The following case was seen by me in consultation with Dr. A. W. 
Xewfield during the summer of 1904 : — 

The infant was breast-fed, but did not seem to nurse well. The lymph nodes at 
the angle of the jaw, the groin, axilla, and various portions of the scalp could be 
plainly felt. The child had laryngeal spasms. Had had as many as twenty-five or 
thirty attacks of laryngismus stridulus. The adenoid tissue at the base of the 
tongue was enlarged. There was also a mass of adenoids in the posterior nares. 
The posterior pharyngeal wall was studded with fungous granulations. The infant 
had a very short, thick neck. The nurse in charge was always afraid the infant 
would die during these spasms. It was necessary to gavage to sustain life. By 

48 (753) 



754 DISEASES OF THE GLANDS OR LYMPH XODES. 

pumping some of the breast-milk and using cows' milk for alternate feedings we 
gradually strengthened the infant. 

Codliver-oil inunctions were ordered to aid in the nutrition of the body. 

When such a condition is found great care must be exercised so as not 
to lower the vitality of the patient, but rather to stimulate nutrition by 
giving arsenic in the form of Fowler's solution in addition to iodide of 
sodium. 

Acute Adexitis. 

This inflammatory condition of the lymphatics is quite common. It 
is usually caused by an infection, or an abrasion of the skin, permitting an 
infection in or about the glands affected. 

The cervical glands are most frequently affected. 

Inflammatory conditions in the nose, throat, the mouth, or on the 
skin give rise to these swellings. 

The axillary glands are frequently swollen, due to septic absorption 
following vaccination. 

The glands of the thigh and the inguinal glands are commonly affected 
when there are irritations or inflammatory lesions involving the genitals, 
or the lower extremities. 

Pathology. — The glands show swelling and infiltration with inflam- 
matory products. The immediate tissues are usually involved. Very fre- 
quently the swollen glands resolve. At other times there is an excessive 
migration of white cells so that the glands break down and abscess results. 

Symptoms. — The glands per se may show inflammatory symptoms, such 
as fever, tenderness, and swelling. It is wise to examine the adjacent parts 
to be sure that the glands are not a secondary inflammatory condition. For 
example, in diphtheria the neighboring glands are usually swollen. If the 
gland only is involved, we have no evidence of reddening or inflammation. 
When inflammation exists involving the neighboring tissues, a reddening 
of the skin takes place. Such cases usually have fluctuations, or soft areas 
can be made out. The glands are swollen, at times reaching the size of a 
hens egg. 

The diagnosis is very easily made. 

The prognosis depends on the condition of the child at the time of 
infection. If tuberculosis exists, the prognosis rs bad. The prognosis of 
acute adenitis in conjunction with acute exanthemata is usually good. 

Treatment. — (a) Abortive; (b) surgical 

Abortive. — The inunction of Crede ointment has served me very well. 
A piece of the salve about the size of a bean should be well rubbed into 
the swollen gland. The rubbing should be continued at least ten minutes. 
Sometimes a leech applied to a gland will reduce the swelling. An ice-bag 
will reduce swelling and sometimes prevent suppuration. Belladonna oint- 
ment and ichthyol, 10 per cent,, with lanoline is sometimes useful. 



ADENITIS. 755 

Surgical Treatment. — When fluctuation is felt, hot fomentations with 
flaxseed meal will be very grateful. An incision should be made, with 
aseptic detail, pus evacuated, and the wound packed with iodoform gauze. 

Later restorative treatment, such as malt, iron, codliver-oil, or the 
syrup of the iodide of iron, should be given. 

Chronic Adenitis. 

Not infrequently we meet with children who have swollen glands last- 
ing months and years, in whom no evidence of tuberculosis or syphilis 
exists. 

This is usually due to repeated attacks of inflammation following 
acute adenitis, or it is the result of chronic inflammation of the skin. 

Pathology. — The glands show an increase in their cellular and con- 
nective tissue elements. They undergo a true hyperplasia. 

Symptoms. — The symptoms consist in a swelling of the glands without 
inflammation or tenderness. In chronic adenitis the glands do not break 
down, hence suppuration is absent. In conjunction with chronic enlarged 
glands we find hyperplasia of the tonsils, so that we invariably have en- 
larged tonsils and adenoids in such conditions. 

Diagnosis. — The diagnosis should be made after syphilis, tuberculosis, 
and other infections, such as diphtheria and scarlet fever, have been ex- 
cluded, so that we can be sure no specific or infectious disease is the origin 
of the trouble. 

The prognosis is usually very good. 

Treatment. — The treatment consists in removing the cause. Middle 
ear inflammation, scalp disease, and pediculosis should be vigorously treated. 
Adenoids and diseased tonsils should be removed. Thus the treatment is 
narrowed down to removing the cause if possible and relying on restorative 
treatment, fresh air, and good nutrition. 

Tubercular Adenitis. 

This condition is due to an invasion of the tubercle bacillus, resulting 
in a tubercular manifestation of the glands. It was formerly believed to 
be "scrofulosis." The pharynx and tonsils seem to be the point of entrance, 
as the glands in the cervical region are usually affected. 

Pathology. — The glands undergo a caseous degeneration which fre- 
quently results in abscess. At times we meet with tubercular lesions in 
various organs of the body. In the glands we note that they are studded 
with miliary tubercles and also find the tubercle bacillus therein. 

Symptoms. — The glands enlarge in various parts of the body; most 
frequently the cervical glands are affected. It is usually a very slow process, 
extending over months ; sometimes years. During this time, from the long 
continued inflammation, evidence of a continued illness is shown. When 



756 



DISEASES OF THE GLANDS OR LYMPH NODES. 



these abscesses form they heal very slowly and frequently leave sinuses or 
ragged scars. 

Henry G., 2 V 2 years old, was brought to my children's service with a history 
of recurring swelling on both sides of the neck and also behind the ear. The child 
was bottle-fed during infancy and had always suffered with dyspeptic trouble and 
constipation. He has had furunculosis of the scalp, which necessitated incisions, 
during the second year. Was troubled with tonsillar and catarrhal trouble, also 
double otitis. 




Fig. 



235. — Case of Cervical Adenitis in which a Positive von Pirquet 
Reaction Appeared. (Original.) 



The glands of the neck are swollen and frequently break down and discharge 
pus. The temperature is not elevated. This suppuration is known as the cold abscess 
type. The general condition is fair. The child is taking maltine with hypophos- 
phites. A restorative diet of cereals, cream, butter, eggs, etc., is given. Attention to 
hygiene, and out-door life is the most important part of the treatment. 

Diagnosis. — This can easily be made when we consider the character 
of the glandular swelling, their tendency to caseation, and to suppuration. 
When the pus is examined, tubercle bacilli are invariably found. 

Differential Diagnosis. — In the beginning this disease is difficult to 
diagnose. We can exclude syphilis by the history of the parents. When 
the history is not obtainable, resorting to anti-syphilitic treatment will 



mumps. 757 

materially aid in eliminating the diagnosis of syphilis. In Hodgkin's dis- 
ease the glands do not suppurate. In simple chronic adenitis there is no 
suppuration. 

Treatment. — Attention to hygienic details is of prime importance. 
The diet should consist of restorative foods in which proteids and fats 
abound. Eestorative medication, such as iron, codliver-oil, iodide of 
sodium, and arsenic, and syrup of iodide of iron are the most useful drugs 
to be considered. 

Head also the treatment outlined in the chapter on "Acute Miliary 
Tuberculosis." 

The surgical treatment of tubercular adenitis should consist in the 
total removal of the suppurating glands, using aseptic precaution, rather 
than to rely on slow spontaneous evacuation of pus by Nature. 

Mumps (Specific Parotitis). 

This is a specific febrile disease, characterized by inflammation of the 
salivary glands. 

Etiology. — This disease is prevalent all over the world, occurring 
usually in the form of local epidemics. It is more marked during the cold 
and wet seasons than in the summer. The disease is disseminated from 
patient to patient by infectious material. Children between 10 and 15 
years of age suffer most. Boys are more liable to be attacked than girls. 
Infantile parotitis is frequently met with. The nursing infant is not exempt 
from this condition. 

The period of incubation, counting from the exposure to infection 
and the appearance of the disease, varies from fourteen to twenty-five days. 
It is usually about three weeks. 

Pathology. — The disease is most likely due to an infection by a micro- 
organism. The salivary glands are probably the seat of invasion. 

Symptoms and Diagnosis. — The disease is preceded by fever lasting two 
or three days. The temperature may reach 104° F., although the usual tem- 
perature is about 101° F. The fever may be so pronounced that delirium 
accompanies the same. The most pronounced symptom is pain and ten- 
derness in one parotid gland. The gland becomes swollen. The swelling 
occupies the space behind the angle of the jaw and below the ear, spreading 
forward on the cheek, and downward along the neck. The edge is ill de- 
fined, and the swelling itself is doughy to the touch. 

Goodhart has reported cases in which the swelling was severe and the 
patient breathed with his mouth open. In such instances the tongue is dry 
and brown, but no serious import should be given thereto. 

The swelling is confined to that portion of the neck between the jaw 
and the sterno-cleido-mastoid muscle. The center of the swelling is im- 
mediately under the lobe of the ear. 



758 DISEASES OF THE GLANDS AND LYMPH NODES. 

The swelling becomes so extreme and the pain so acute that the patient 
can hardly do more than separate the upper and lower jaw. The submax- 
illary gland on the same side becomes affected within a day or two and there 
is a large swelling below the jaw. Soon afterward the opposite parotid 
and submaxillary glands may also become involved. Goodhart states that 
a swelling of the cervical lymphatic glands may be the only local signs of 
mumps. 

There is usually a general malaise. The swelling lasts four or five 
days and then subsides. Suppuration never results. The amount of saliva 
secreted is not altered. It may be excessive or on the other hand diminished. 

Differential Diagnosis. — The glandular swelling in mumps has fre- 
quently been mistaken for diphtheria. In the latter disease the parotid 
glands are not affected. The patient rarely encounters difficulty in opening 
the mouth, even when the cervical lymph glands are enlarged. 

The differential diagnosis between mumps and diphtheria must be 
made by a careful inspection of the fauces and tonsils and noting the ab- 
sence or presence of membrane. 

There are other conditions which may be accompanied by parotitis. 
In enteric and other fevers in various disorders of the abdominal cavity, 
one or both parotids may be inflamed. In these conditions, however, sup- 
puration of the parotid gland may ensue. 

Prognosis. — This is almost always favorable. Goodal and Washbourn 
state that during ten years in England and Wales there were but eighty 
deaths registered among the entire population. These authors suspect 
diphtheria as the cause of most of these deaths, reported as mumps. 

Complications. — The most disagreeable complication is orchitis. This 
usually commences when the disease has progressed several weeks. It is 
accompanied by fever, sometimes chills. The body of the testicle and not 
the epidermis is involved. As a rule ice-bags or leeches aided by rest will 
relieve this condition. The attack usually lasts several days, but may be 
prolonged several weeks. 

Treatment. — Local: Hot fomentations, consisting of ground flaxseed 
meal to which a few drops of laudanum have been added, are very grateful 
and well borne. They are to be applied between two thicknesses of cheese- 
cloth. These poultices should be renewed at intervals of one-half hour. 
Among the newer local remedies, antiphlogistine, warmed and applied in 
the form of a salve, has been advocated. 

The occasional application of a leech at the site of the swollen parotid 
will be found advantageous in some instances. 

An ice-bag can sometimes be used to advantage. The local application 
of tincture of iodine can be recommended. 



MUMPS. 759 

The inunction of: — 

IJ Unguentum belladonna 6 drachms 

Unguentum hydrarg. ciner 3 drachms 

M. Ft. ungt. 

To be rubbed in swollen glands every three or four hours, may be tried. 

Another drug which is quite serviceable is ichthyol, to be applied sev- 
eral times a day, in the following manner: — 

R Ammonium sulpho. ichthyol 2 drachms 

Lanoline 1 ounce 

M. Ft. unguentum. 

To be thoroughly rubbed in swollen glands. 

The local application of a 5 per cent, iodoform collodion painted over 
the inflamed region, several times a day, or a 10 per cent, salicylic collodion 
applied several times a day is at times beneficial. 

The inunction of a 15 per cent, iodide of potassium ointment will be 
indicated if there is a suspicion of syphilis in the case. 

Constitutional Treatment. — Barely do we require internal medication 
in this disease. If, however, there is high fever, sponging the surface of 
the body or cold packs are indicated. The internal administration of a mild 
laxative, such as citrate of magnesia, is grateful and beneficial. 

Five-grain tablets of rhubarb and magnesia will be required if consti- 
pation exists. 

Owing to the infectious nature of this disease, the first rule should be 
to isolate. The isolation should be thorough and continued at least ten 
days from the beginning of the illness. 



1 



CHAPTEE V. 

DISEASES OF THE DUCTLESS GLANDS. 

Cretinism (Myxedematous Idiocy — Myxedema). 

Cretinism is a form of idiocy associated with pachydermatous 
cachexia. 

Etiology. — In my own cases ps}'chical disturbances in the mother 
seemed to result in cretinism. Worriment and fright seemed to have some 
etiological relationship to the development of myxedematous idiocy. 

In two cases of mine the mother suffered with mental depression, con- 
stant worry, and hysterical symptoms during pregnancy. 

Pathology. — We are indebted to Fletcher Beach for a series of careful 
post-mortem investigations which have thrown considerable light on the 
nature of this disease. We know that cretinism is due to the absence of 
the internal secretion of the thyroid gland. In some instances the gland 
is congenitally absent. This condition also results when the thyroid gland 
is removed by surgical means. It is safe, therefore, to assume that the loss 
of the function of the thyroid gland causes cretinism. 

Holt believes that cretinism is in some instances associated with goiter. 
This disease occurs sporadically in our country. 

Symptoms. — The characteristic manifestations are very apparent dur- 
ing the first year of a child's life. Sometimes distinct evidences of cretinism 
can be seen as early as the third month after birth. The child is short in 
stature and light in weight compared to the normal infant. The extremi- 
ties, particularly the fingers, are short and thick. The lips are thick. The 
tongue is broad and thick, and constantly protrudes from the mouth. The 
fontanel is late in closing. The nose is broad, flat, and upturned. The 
nostrils are wide open. The hair is coarse and straight (straw-like). Den- 
tition is delayed, and when the teeth do appear they are very poorly formed. 
The skin of the entire body is thick and dry, but does not pit on pressure. 

The infant is stupid, and it is very noticeable that we are dealing with 
deficient mental development. 

In the supra-clavicular regions there are regularly formed pads of fatty 
tissue, so that the neck is short and thick (Tuttle). The thyroid gland 
cannot be felt unless it contains a tumor. The abdomen is large and 
prominent and an umbilical hernia is frequentlv present. 

Constipation of a very obstinate character is usually met with and 
persists for a long time. The temperature is subnormal. The thyroid gland 
(760) 



CRETINISM. 



761 



Spokadic Cretinism. 

Fig. 236.— Child. Age 2 
years, 2 months. (Origi- 
nal.) 

Fig. 237.— Same child. Seven 
months after continued thy- 
roid treatment. (Original. ) 

Fig. 238.- Same child. Age 
3 years, 9 months. One 
year and seven months after 
continued thyroid treat- 
ment. ( Original. ) 




Fig. 236 







Fig. 237 



Fig. 238 



762 DISEASES OF THE DUCTLESS GLANDS. 

is absent or cannot be felt. In palpating the thyroid region we can feel the 
trachea. In some cases there is a hypertrophied hypothenar eminence on 
the palms of the hands. The face in all cases has the prognathous expres- 
sion (Koplik). 

Diagnosis. — The value of an early diagnosis in this condition is more 
important than in any other disease with which we are brought in contact. 
The diagnosis can usually be confirmed after a short period of thyroid treat- 
ment. The specific results of treatment are more apparent in this condi- 
tion than in any other infantile derangement with which we are con- 
fronted. 

Case I. — Frances P. 1 was referred to me by Dr. L. F. Haas. She was the 
seventh child of this family. All the other children were perfectly normal. The 
labor was normal. The child was born before the doctor arrived. 

Family History. — The father is healthy. The mother is strong and healthy. 
During the pregnancy the mother constantly cried on account of family trouble- 
Her husband was out of work. The mother frequently had hysterics. Similar 
psychical disturbances were never present while pregnant with the six other children, 
who are all strong and healthy. 

History Given by the Mother. — The mother noticed that the child had short 
limbs. That she was not bright mentally. That when 1 1 / 2 years old she could 
neither walk, talk, nor support her head. The tongue was very thick and protruded 
almost constantly while awake, as well as when asleep. The hair did not grow. 
The nose was short and flattened. The skin was yellowish and dry. The child had 
a jaundiced appearance. Constipation since birth. The bowels were moved with 
difficulty. The infant was breast-fed until it was fifteen months old. Up to this 
time there was no sign of dentition. She was taken to the Babies' Hospital, 
which necessitated her being weaned from the breast. She remained in the 
hospital about two weeks. When sixteen months old, one month after thyroid 
treatment was commenced, the first tooth appeared. The child was successfully 
vaccinated at the end of the first year. 

During its first year and up to the time that it was taken to the hospital, it 
did not suffer with any infectious disease. 

My first examination was on December 8, 1902. The child at that time was 
2 years, 2 months old. The following conditions were found: — 

The child can neither walk nor talk. The tongue is very thick and protrudes 
constantly. The lips, the eyelids, and the skin of the face are thickened, coarse, and 
rough. The nose is short and flat. The skin has a yellowish jaundiced appearance. 
The fontanel is widely open both anteriorly and posteriorly. The face is broad and 
the eyes are set very wide apart. There is a marked depression on each side of the 
temporal bone. There is a marked frontal protuberance. The child had nine 
teeth when twenty-two months old. As previously stated the first tooth appeared 
one month after the thyroid treatment was commenced, or when the child was 
sixteen months old. The body is well developed — fat. There is no evidence of 
rachitis. The chest and spine show evidences of good nutrition. The length of the 
body was 50 a / 2 centimeters, or about 20 inches. The secretions of the body were 
very torpid. Constipation of a very obstinate form was encountered. There were 
several fatty growths in the sterno-cleido-mastoid muscle. 

1 Three cases of cretinism were presented by me at the Section of Pediatrics 
of the Few York Academy of Medicine, February 11, 1904. 



CRETINISM. 763 

The child had a violent fear of water, so much so that the mother had difficulty 
in bathing her. The hair is very thick and straw-like. The thyroid gland cannot 
be felt. 

The pulse was 90 and of a full bounding character. There was a subnormal 
temperature which was never higher than 98° F. in the rectum in the evening. 
Respiration was 10 while quiet and 24 while crying. The urine showed traces of 
indiean. evidently due to the constipation. No albumin or sugar was found. Micro- 
scopically no uric acid crystals; no casts, and no bacteria were found. 

When the treatment was first commenced, 1 grain of thyroid was given three 
times a day. This dose was rapidly increased so that after the first week the child 
took 2 Vi grains three times a day. The heart was carefully watched and no 
disturbance noted from the quantity of thyroid given. In addition, 10 drops of 
pure codliver-oil was given three times a day. Cereals, milk, chicken soup, broths, 
and acid fruits, such as oranges, lemons, and cranberries, were ordered. Fresh air and 
bathing, with vigorous friction, concluded the hygienic treatment. Under this 
vigorous treatment the child developed very fast. The length of the body was 
58 1 / 2 centimeters at the end of the first month of this treatment. The growth, 
therefore, in one month amounted to 8 centimeters or 3 Vs inches. The obstinate 
constipation was improved and the bow T els became regular. The teeth have 
appeared at regular intervals. The facial expression has changed. The child now 
comanences to walk, as also to talk, she says "mamma" and "papa." 

The fear of water and to be bathed is past. She no longer cries when she sees 
water. At the end of 1 year, the length of her body is 85 centimeters or 33 '/a 
inches, so that she has grown in 1 year 34% centimeters or 13% inches. 

The child is still taking thyroid and is progressing favorably. 

Table No. 100. — Length and Growth of Body. 



Age. 



Length of Body. 



Gain in Growth of Body. 



2 yrs. and 2 mos. 50 J centimeters (19-^f inches) 

2 yrs. and 3 mos. ; 58 w centimeters (23^ inches) 

3 yrs. and 3 mos. | 85 centimeters (33 J inches) 



1 mo., 8 centimeters (3£ inches) 
12 mos., 34 J centimeters (13J inches) 



Case II. — Rosie H., born January 1, 1902, now over 2 years old, was first seen 
by me when she was eighteen months old. 

Family History. — Father living, is somewhat dyspeptic. Has no specific disease. 
The mother is a very nervous woman, otherwise in good health. This is her first 
child. She has had one other pregnancy of eight months which was still-born, 
believed to have been an asphyxia neonatorum. No miscarriages. No lues. 

Child's History. — She was breast-fed for seven months, later she received equal 
parts of milk and water. When first seen by me at the age of eighteen months, she 
was still fed on equal parts of milk and water. There has always been severe 
constipation, and streaks of blood have frequently been seen in the stool from severe 
tenesmus. The examination of the child at that time showed coarse, sparse hair, 
and a very rough skin. The tongue and the lips were very thick. The tongue 
always protruded from the mouth; breathing was difficult. There was constant 
snoring, and the mouth was always open. The thorax was decidedly rachitic; there 
was a funnel-shaped depression, and also a kyphosis and an umbilicated hernia. The 
child could neither stand nor talk. There was no evidence of teething. The appetite 
was poor. The temperature was subnormal, 98 V&° in the rectum. The pulse was 



764 DISEASES OF THE DUCTLESS GLANDS. 

100, small, and feeble. The heart sounds muffled. A hsemic murmur was plainly 
heard at the apex and also in the vessels of the neck. It was impossible to secure 
a specimen of urine for examination. A drop of blood was examined and showed a 
decreased number of red blood-corpuscles and a marked leucocytosis. The diagnosis 
made was sporadic cretinism. The circulation was poor and there was a slight 
oedema constantly present. The feet and hands were frequently cyanotic, and always 
felt cold. The anterior fontanel was widely open. Growth was stunted as the 
length of the body was only 55 centimeters. The naked weight when 1 1 / 2 years old 
was 11 pounds 13 ounces. ^Tien first seen by me there was neither muscular nor 
bony development which could be considered normal. At eighteen months the child 
had had no teeth. At twenty-two months the first tooth appeared. The muscles of 
the body were limp and flabby. The child could not support her head nor was there 
good support to the spinal column. The patellar reflexes were but slightly present. 

Treatment. — The treatment consisted in giving fresh, raw milk warmed to body 
temperature. In addition to the milk, steak juice, orange juice, potato flour, and 
the usual antiscorbutic remedies were ordered. Fresh albumin, using the raw white 
of egg, and vegetable proteids, such as pea soup and lentil soup, were very well 
assimilated. 

The medicinal treatment consisted of two drugs. Thyroidine was given in doses 
of V 8 grain three times a day, and gradually increased until 3 grains were given three 
times a day. The other drug was Fowler's solution given in 1 drop doses, increased 
to 3 drops three times a day. It is now about six months since the treatment was 
commenced. The child has grown in length from 55 centimeters to 69 centimeters 
and the weight has increased from 11 pounds 13 ounces to 17 pounds. 

Case III. — Rosie N. was first seen by me on June 28, 1902. She was then 
seventeen months old. 

Family History. — Father is healthy. No family history of tuberculosis, syphilis, 
or any other taint. The mother is in good health and has never had any serious 
illness nor miscarriage. This was her first pregnancy. The mother's condition was 
good, there was no traumatism nor any psychic disturbance. The infant was born 
without the aid of instruments. It was a perfectly normal delivery. The mother 
menstruated while nursing the infant. 

Personal History. — The infant was nursed about sixteen months. She did not 
seem to thrive since she was three months old. Severe constipation had always 
existed, and was present when I first saw her. She could neither stand, walk, nor 
talk. Backwardness in development was very apparent. Spasmus nutans was 
present. The fontanel was widely open. She showed no signs of intelligence. The 
hair was coarse and straight. The extremities were short. The growth stunted. 
She presented a squatty appearance. The skin was rough, thickened, and large 
eczematous patches covered the arms and legs. The child was sent to me by Dr. 
L. Weiss, who had her under his care for the relief of the eczema. The lips were 
thick. The tongue was thick and protruding. She had two lower incisors; no 
other evidence of dentition. The facial expression was senile and corresponded with 
that of a typical cretin. She was restless by day and suffered with insomnia by 
night. The urine was examined and contained no albumin nor sugar. Slight traces 
of indican were seen, microscopically nothing pathological. The blood examination 
showed four million six hundred and twenty thousand (4,620,000) red blood-cor- 
puscles, and seven thousand two hundred (7200) white cells. 

The percentage of haemoglobin taken with Gower's instrument was about 40 
per cent. As digestion was very poor I decided to syphon off the gastric contents 
two hours after a meal and to examine the same chemically. 



CRETINISM. 



765 



Sporadic Cretinism. 

Fig. 239. — Child. Age 1 

year, 5 months. (Orig- 
inal.) 

Fig. 240. — Same child. Age 

2 years. (Original.) 

Fig. 241. — Same child. Age 

3 years, 5 months. (Orig- 
inal. ) 




Fig. 23S 




Fig. 240. 



Fig. 241. 



766 



DISEASES OF THE DUCTLESS GLANDS. 



Feeding. — The feeding was barley water. About 5 cubic centimeters were 
syphoned off, which showed traces of peptones, starch, and sugar: HC1 was absent 
by Gunzberg's test. I am indebted to Mr. Charles La Wall for his assistance in the 
chemical analyses of the gastric contents, made a number of times. 

Equal parts of milk and barley water were fed every few hours. Thyroid 
treatment was commenced ; 1 / 2 grain of the desiccated powdered thyroids was ordered 




Fig. 242.— Cretinism. Age 7% years. Height 
26% inches. Front view. g 



Fig. 243.— Cretinism. Age 1% years. Height 
26% inches. Back view. 



three times a day. The dose was gradually increased and the child now receives 3 
grains three times a day. There was no cardiac disturbance from this dose. 

Lemon juice, orange juice, raw albumin, and vegetable soups were ordered. 
The child's condition improved. The specific effect of the thyroid was very apparent. 

Case IV. — Gussie S., 1 7 years and 3 months old when she came under my obser- 
vation. She was born January, 1897. She is the oldest of four children. The other 
children are to all appearances healthy, as are also the parents. 



1 1 regard this case as the most complete type of cretinism that I have ever 
seen. The notes were kindly furnished by Dr. A. E. Isaacs, in whose practice the case 
occurred. 



I III- 1 IMSM. 



;<;; 



Family History. — The mother claim- to have had a severe fright during her 
sixth month of pregnancy, and attributed the child's mental deficiency to this psych- 
ical disturbance. There is no history of any condition similar to this child's on 




Fig. 244.— Cretinism. Same case. Age 8 years. 
Height 33% iuches, gain 6% inches. 



Fig. 245. — Cretinism. Same case. Age 8 years. 
Heigh i, 33% inches, gain 6% inches. Back view. 



either side of the family. Parents are natives of Russia. They are 13 years in this 
country, and do not know of any such disease in their native country. The parents 
are not related. 

Feeding. — The child was breast-fed for about two years. She did not receive 
any other food during this period. When the child was thirteen months old the 
mother's menstruation returned. The mother continued to nurse the child until the 
end of the second year, although she continued to menstruate every month. 

Nothing unusual was noticed about this child until the end of her first year. 
She cried very little and slept a great deal. At about 1 year of age parents noticed 
that she differed from other children of the same age. No teeth appeared. She 






768 



DISEASES Of THE DUCTLESS GLAXDS. 



made no attempt to walk or stand. Never laughed or smiled, was always apathetic 
and took no interest in her surroundings. There was no appreciable growth in 
height from 1 to 7 years. The same dresses always fitted her. In her fifth year 
she was for a period of six months yery cross and restless, but this disappeared as it 
came, without any known cause. 




Fig. 246.— Cret 
Height 37% inches, gain 4% inches 



Age 9 years. 
Front view. 



Fig. 247.— Cretinism. Same case. Age 9 years. 
Height 37% inches, gain 4% inches. Back view. 



She cut her incisor teeth at 3 years of age and the rest at 4 years. She has 
never had convulsions or any other sickness except measles when 4 years of age. 
She began to stand on her feet with assistance when 3 years old. She did not speak 
a word until 5 years old, from which time till I took charge of her she could say 
no more than "papa" and "mamma." 

"When she came under my observation, she was 26 V 2 inches high. She weighed 



CRETINISM. 



769 



25 V3 pounds and was quite stout in proportion to her height. Her head was large 
in proportion to her body. The lips wore thick. The nose flat and depressed between 
the eyes. The neck was very short. No sign of enlarged thyroid, large blue eyes, 
teeth in fair condition, complexion dark, hair dry and of a rusty black color. 







Fig. 248.— Cretinism. Same case. Age 11 years. 
Height 39% inches, gain 2 inches. Front view. 



Fig. 249.— Cretinism. Same case. Age 11 years. 
Height 39% inches, gain 2 inches. Back view. 



Hearing, sight, and smell apparently good. Voice not out of the ordinary. 
The extremities were short and thick, lower ones were bow-legged. The ends of the 
bones were large. The belly was large and its prominence exaggerated by a decided 
anterior curvature of the spine. Intelligence was almost nil, temperament very 



77» DISEASES 07 THE DUCTLESS GLANDS. 

irritable, does not cry. but becomes very angry. She never asks for food, eats little 
and only what is given to her. The bowels were constipated, moving only once in 
two days. She never asks to pass stool or water. Had external haemorrhoids, which 
bled occasionally. When awake was constantly sitting. Cannot walk alone and 
only a few steps when assisted- She slept well. Pulse was 96 and regular. 

Has had no treatment for three years. Previous to this time parents had been 
all over with her and tried everything suggested, without avail- 
On January 25, 1897, I put her on 3 grains, once a day, of desiccated thyroids 
(Parke, Davis & Co.). On February 18th dose was increased to 4 grains daily, but 
after a week the dose had to be reduced to 2 grains, as the pulse rose to 120 and the 
child became irritable. Otherwise, some improvement was already noted in her 
general condition; she could stand better and moved her bowels daily. After another 
week (March 6th) the dose was increased again to 3 grains daily and was continued 
so till I saw her on March 21st, when I found her pulse 144, strong and bo unding . 
She had become considerably thinner, having lost 1 V» pounds in weight in spite of 
the fact that she had gained 2 inches in height. This gave her a much more natural 
appearance. She also had a more intelligent facial expression, talked more and 
decidedly better, walked a short distance without assistance, and ate better. 

On account of the accelerated pulse and loss of flesh, I decreased the thyroids 
again to 2 grains daily. From this time on there was a gradual improvement in all 
the symptoms. By the middle of April she was running about the streets, playing 
with other children, and asked for her food. In May she began to tell when she 
wanted to move her bowels, gradually gained in intelligence, spoke more and articu- 
lated better. The dose of the thyroids was gradually increased until she was taking 
5 grains daily (July), which she continued for more than a year and a half without 

-mptoms of intoxication. 

I had the honor of presenting her before the Society 1 in 1898 after one year's 
treatment, when she had gained 6 3 /« inches in height. The privilege was accorded 
me again in 1899 when she had gained an additional 4 z / 3 inches. The average growth 
of a normal child of her age is less than 2 inches a year. She had gained orer 
eleven (11) inches in two year*. 

As interesting as this case is so far, the most significant and interesting part of 
it comes now. I lost track of the patient in January, 1899, and she took no medicine 
from that time untQ I saw her again in December, almost a year later. My note- 
book records the fact that there was no increase in height and that her general 
appearance was not good. Although I ordered the thyroid extract it was not given 
again until I saw the patient one-half year later, on June 1st, 1900, and again there 
was no increase in height or improvement in general condition. The patient's next 
visit was in February, 1901, when she reported that 5 grains of the thyroid had been 
given daily from June 1st to December 24th. Measurement showed a gain of 2 inches 
in height (39 V 2 ). Her general appearance was much better and she had been going 
to school for a few weeks. 

If any proof be necessary as to the efficacy of the thyroid principle in cretinism, 
or as to the thyroid gland and its secretion being essential to the proper physiological 
workings of the human body, the history of this case supplies it. Take the one 
symptom of stature. From 1 to 7 years of age, without the administration of 
thyroids, there was no increase. From 7 to 8 years, with thyroids, there was a 
growth of 6 */« inches. From 8 to 9 years, also with thyroids, there was a growth of 
4 V# inches. From 9 to 10 years, without any thyroids, there was no growth. From 



Eastern Medical Soci~:- N"r~ Y 



CRETINISM. 771 

10 7 a to 11 years, with thyroids again, 2 inches were gained. All other manifesta- 
tions of this cretlnic condition underwent corresponding fluctuations with the ad- 
ministration of the extract, but changes in stature being the most evident, serve 
best to illustrate the progress of the case. 

To contrast her previous with her present condition as well as to show her 
appearance during the period of her improvement no better means could be utilized 
than the accompanying photos. The first pair was taken in February, 1897, the 
second in 1898, the third in 1899, and the fourth in February, 1901. 

She is now sufficiently intelligent to go to school. She plays as a child should 
and her general health is very good. She has yet the physical marks of her previous 
condition in the peculiar features, the short neck, and the spinal curvature with 
the abdominal prominence, though they have all improved, especially the spine and the 
abdomen. Her height is about 12 inches short of what it should be at her age, 11 
years, but if the rapid rate of growth continues she will gain a good part of it. 

September, 1901. — Has taken little medicine. Height about the same. 

April 27, 1902. — Has taken medicine one and one-half months since last visit. 
Height, 41 V* inches ; goes to school. 

September 4, 1902. — Has taken 5 grains daily since April 27th. Looking and 
feeling well. Losing flesh, feels cold at night, hands tremble when taking things to 
mouth since six weeks. Pulse, 188. Height, 41 1 / 2 inches. Discontinued thyroids 
three weeks. 

I saw case on December 20, 1902. No thyroids since last week. Patient is 
gaining flesh, shivering (trembling) stopped. Pulse, 72. Goes to school, has 
mastered her figures only (is almost 13 years old). Ordered 2 1 /* grains thyroid 
daily. 

When last seen, April 20, 1904, the mother stated the girl had been going to 
school for the last two years. Very little mental progress has been made during this 
time. She reads an elementary primer and can remember figures. Has taken thyroid 
but four months out of the last sixteen months. Her height is 43 V 4 inches. She 
has gained in the last sixteen months about two inches. Her pulse-rate is 72. 

Prognosis and Course. — The sooner treatment is instituted the better 
the result. When this condition is neglected, children become worse and 
worse until finally they are beyond medical aid. 

It must be borne in mind that thyroid must be given for years if last- 
ing results are to be obtained. Children will go backward at once if we 
discontinue our treatment, even though the same has been continued for 
some years. An interesting study is the continuous growth including men- 
tal development plainly seen in the illustrations of cases in this chapter. 

Treatment. — The most important part of the treatment consists in 
administering from 1 to 5 grains of the dessiccated extract of thyroid. 
This replaces the active principle of the normal thyroid gland. I have 
used with very good success thyroidin, from x / 2 to 2 grains three times a 
d"ay, with equally good result. 

Great care should be taken to watch the pulse-rate while giving thy- 
roid. The pulse will sometimes increase from twenty to forty beats after 
the administration of 1 or 2 grains of thyroid. The moment we find an 
exaggerated pulse-rate, it will be necessary to reduce the dose of thyroid 



772 DISEASES OF THE DUCTLESS GLAXDS. 

at least one-half. A flabby, fat child will at once lose weight, and an impor- 
tant feature of successful treatment is an increase in height. 

Thyroid Implantation. — Implantation of sheep's or lamb's thyroid 
(heterogeneous), or from the human being (homothyroid), has been advo- 
cated by some. In one case of mine, operated by Dr. Howard Lilienthal, 
the implantation of lamb's thyroid was tried. Several pieces were im- 
planted in the peritoneal cavity. Some improvement was noted. 

We must not, however, blindfold ourselves to the belief that when we 
supply the missing internal secretion, namely, thyroid, that we have ful- 
filled all indications. 

The diet must be regulated and the child given a large portion of pro- 
teids — milk, meat or meat extracts, fresh beef blood or roast beef juice, 
orange juice, fresh eggs, and all cereals must be given as body builders. 
Fresh air and a general attention to the hygienic condition of the child are 
very important. Massage, gymnastics, and exercise should not be over- 
looked. 

If the appetite is poor 1 to 2 -minim doses of the tincture of nux vomica 
will do good. Butter and codliver-oil are valuable adjuncts. 

Exophthalmic Goiter (Hyperthyrea, Basedow's Disease, 
Graves's Disease). 

This disease has occasionally been seen in children. It is supposed to 
be due to a hypersecretion of the thyroid gland. Sachs believes that hered- 
ity is a more important factor than excitement or fright. Epileptic and 
alcoholic parents certainly predispose to this condition in children. 

Symptoms and Diagnosis. — There are three symptoms of importance 
which should be noted : — 

1. The enlargement of the thyroid. 

2. Palpitation of the heart (tachycardia). 

3. Protrusion of the eyeballs (exophthalmus). 

The blood tension is increased, hence haemorrhages from the nose, . 
stomach, or intestines are quite common. Disturbances of vision due to the 
exophthalmus are never described. The thyroid enlargement is usually 
bilateral. Muscular tremors are also noted. The diagnosis is easily made by 
recognizing the symptoms above described. There is a physiological hyper- 
emia of the thyroid which is entirely different from goiter. 

Prognosis. — Cases seen by me have all assumed a chronic tendency. I 
have never known death to occur directly from this condition. When death 
occurred it was due to some complication. 

Treatment. — Spartein sulphate, strophanthus, digitalis or belladonna 
combined with iodide of sodium may be tried. The galvanic current is 
strongly advised by some writers. Recently x-ray treatment has been 



DISEASES OF THE THYMUS GLAND. 773 

used in conjunction with the above mentioned drugs. The danger of 
x-ray dermatitis should be remembered by those having little experience 
with light treatment. 

The use of thyroid has been suggested, but it has failed to do good in 
my hands. 

Acute Thyroiditis. 

Inflammatory conditions such as abscess have been described as a com- 
plication of the infectious diseases. The migration of streptococci or other 
pyogenic bacteria may give rise to suppurative inflammation. The treat- 
ment is surgical. 

Abnormality of the Thyroid. 

Syphilitic gummata and tuberculosis have been found in rare instances. 
Malignant disease involving the thyroid has been reported among infantile 
disorders. 

Diseases of the Thymus Gland. 

In rare instances the thymus gland may persist until the twentieth year 
or even later in life. When such a condition exists mechanical pressure has 
caused dyspnoea of a serious nature. Asthma has been reported by some 
clinicians in which an enlarged thymus was found, hence the term "thymic 
asthma." Sudden death has occasionally been caused by an enlarged thy- 
mus. This has been especially noted in children with rickets. Abscesses 
have been reported in the thymus by Dubois. Syphilis and tuberculosis have 
rarely been found. 

Eeich says: "The absolute dullness of the thymus, as determined by 
light percussion, is irregularly triangular in outline, the base being made 
by the outline connecting the two sterno-clavicular articulations, the blunt 
apex situated at the level of the second rib or slightly below it, and the 
sides a little beyond the edges of the sternum. The larger half of this 
triangle of dullness usually falls to the left side. When the limits of dull- 
ness, as given above, vary by one or more centimeters, or obscure the pul- 
monary resonance between the upper line of cardiac dullness and the lower 
lateral limits of thymus dullness, an enlargement of the thymus is probable. 
The thymus dullness is present until the end of the fifth year, after which 
it is inconstant/' 

Diagnosis. — The diagnosis of diseases of the thymus gland is frequently 
impossible. An infiltration or swelling of the area surrounded by the thy- 
mus gives rise to symptoms of dyspnoea, from pressure upon the pneumo- 
gastric nerve. The same symptoms are also found when the thymus itself 
is enlarged. When the lymph glands in the anterior mediastinum are 



774 DISEASES OF THE DUCTLESS GLANDS. 

swollen, dullness on percussion is rare unless there is a cheesy infiltration 
of the lymph glands, according to Eeich. 

Treatment. — Symptomatic treatment only should be instituted. The 
iodide of sodium in very large doses may be tried. 

Diseases oe the Adrenal Glands. 

Pathologists have frequently described haemorrhages into the adrenal 
glands in the new-born infant. Diseases per se, excepting cancer, have not 
been described. There is still considerable to be learned concerning the 
physiology of these glands. 

Addison's Disease. 

This rare condition is occasionally described. Literature records about 
twenty cases in all. 

Symptoms. — The symptoms of the disease consist of a deep yellowish 
or bronzed pigmentation of the skin. It is found on the exposed parts of 
the body, such as the hands and head. The mucous membranes of the mouth 
and vagina are also pigmented. White areas of skin are scattered over the 
body. Vomiting, diarrhoea, and nervous symptoms are noted. Anaemia is 
usually very marked. 

Diagnosis. — In the diagnosis of this condition it is necesary to exclude 
pigmentation of the skin due to metallic poisons, such as argyria, from the 
internal administration of nitrate of silver. Arsenic and lead have been 
reported as causative factors of bronzed skin. 

Prognosis. — While most authors report the outcome as fatal, some few 
recoveries have been noted. In a case seen by me recovery took place after 
several years of treatment. 

Treatment. — We have no specific treatment for this condition. Some 
authors advise the administration of the raw or cooked adrenal glands of 
the sheep. The dry extract in tablet form has been isolated and 1-grain 
doses of this extract may be given three times a day. When the gland 
itself is used, one-half to one gland may be given in twenty-four hours. 

The value of hygienic and dietetic measures I regard as more impor- 
tant than medication. 



PART IX. 

DISEASES OF THE NERVOUS SYSTEM, 



CHAPTEE I. 
FONTANEL. 



The posterior fontanel is usually closed at the end of the second month. 
The anterior fontanel normally closes between the sixteenth and twentieth 
months. If the fontanel is open at the end of the second year, then rickets 
or other abnormality may be considered. A fullness of the anterior fontanel 
and bulging of the same at the end of the second year is pathological. (See 
chapter on "Hydrocephalus.") Premature closure of the fontanel fre- 
quently occurs in microcephalus and also in congenital idiocy. This prema- 
ture closing interferes with the proper growth and development of the brain. 

Shape of the Head. — Peculiar shapes of the head are met with unde" 
perfectly normal conditions. An interesting study is the series of outline 
sketches of the head which show the modifications in form produced by 
labor and also the normal sketches of the head. 

Circumference. — The average circumference of the head at birth in 446 
full-term infants taken in about equal numbers from the Sloane Maternity 
Hospital and Xew York Infant Asylum, quoted by Holt, was as follows : — 

Average circumference of the head, 231 males.. 13.90 inches (35.5 centimeters) 

Average circumference of the head, 251 females 13.52 inches (34.5 centimeters) 

Total 446 infants. 13.71 inches (35.0 centimeters) 

Auscultation of the Anterior Fontanel. — A bruit is occasionally heard 
over the anterior fontanel. (Plates 22, 23.) It is a blowing sound 
similar to that heard in the vessels of the neck during anaemia or in chlorotic 
girls. I have described this condition in the chapter on "Rachitis." 

Percussion of the Skull. 

MacEwen, in his treatise upon the pyogenic infective diseases of the 
brain and spinal cord, says : "When the lateral ventricles are distended with 
serous fluid, as would be occasioned by cerebral tumors pressing on the 
fourth ventricle, or by occlusion of the veins of Galen or otherwise, the per- 
cussion note is markedly altered, the resonance being greatly increased. 

(775) 



776 DISEASES OF THE NERVOUS SYSTEM. 

Outline Sketches of the Head, Showing the Various Diameters. 




Fig. 250.— Sagittal Section of 
Normal Head of Seven and One-half 
Months' Foetus, Half Natural Size. 
(After Ballantyne.) 



Fig. 252.— Sagittal Section of Normal 
Head, Half Natural Size. ( After Budin, ) 




Fig. 251. — Normal Head as Seen 
from Above, Half Natural Size. (After 
Budin. ) 



Fig. 253.— Sagittal Section of Head Im- 
mediately After Normal, Easy Labor, 
Half Natural Size. (After Ballantyne. ) 



Besides the increased resonance, there is an important feature which may be 
demonstrated : The percussion elicited at a given spot on the cranium, such 
as the pterion, varies according to the position of the head. While the per- 
son sits with the head upright, the most resonant note is brought out by 
percussion toward the basal level of the frontal bones and the squamous 



OUTLINE SKETCHES OF THE HEAD. 



77 



Outline Sketches of Head of Infant, Showing the Modifications in Fobm 
Produced by Labor, itc. 



Fig. 254.— Sagittal Sec- 
tion of Head Immediately 
After Labor (O. D. P. 
Position). (After Ballan- 
tyne. ) 




Fig. 255.— Sagittal Sec- 
tion of Head Immediately 
After Labor, Half Natural 
Size. O. D. P. Position. 
(After Budin. 



Fig. 256,— Sagittal Section 
of Head of Infant Six Days 
Old, Half Natural Size, 
f After Ballantyne. ) 




778 DISEASES OF THE NERVOUS SYSTEM. 

portion of the parietal. If the patient hangs his head to one side, so that 
one parietal is placed fairly below the other, the greater resonance is found 
on percussion of the lower parietal. Eeverse the position and the same note 
is elicited on the opposite side of the head, which is now the lower, the 
greater resonance being found at that part of the skull nearest the lateral 
ventricles, and which for the time is at the lowest level. 

"These observations tend to indicate that the quality of this note is 
not dependent on the mere density of the diameter of the cranium, but to 
a large extent upon the consistence or arrangement of the intercranial con- 
tents relatively to the osseous walls. . . . The exact mechanical quality 
of the note is difficult to describe, but, when heard, it conveys the idea of 
hollowness. One such case, in which the above phenomena were clearly 
marked, was observed to a conclusion. The percussion note was not so clear 
at first as it ultimately became, the resonance increasing as the disease 
advanced. 

"In tumors of the cerebellum it is an aid to diagnosis, and when present 
with abscess it points to an involvement of the cerebral fossa." 

The Brain. 1 

In the new-born the dura mater is closely adherent to the skull, so that 
extravasations between the dura mater and the skull are unknown. 

Fluid in the Subarachnoid Space. — In infancy and childhood more 
fluid is found in this space than in adult life. McClellan believes that 
"hydrocephalus due to an excessive amount of fluids in the ventricles of the 
brain may be caused by the closure of a small opening in the pia mater 
which is found at the inferior boundary of the fourth ventricle known as 
the foramen Magendie/' 

Blood-vessels of the pia mater are so delicate that blood pressure, trau- 
matism, etc., may cause haemorrhage into the subarachnoid space, resulting 
in monoplegia, hemiplegia, or^iplegia. 

Growth and Development of the Brain. — From birth until the seventh 
year is reached the brain grows very rapidly; after the seventh year the 
growth is slow. 

Weight of the Brain. — The weight of the brain of the new-born infant 
is one-third that of the adult. In male and female children it is approxi- 
mately the same at birth, although later on the male brain grows more 
rapidly than the female. When a child is between 7 and 8 years of age, 
the brain reaches the adult size and weight. There is from this time on a 
slight increase in the weight up to the twenty-fifth year. 

Vierordt states that the increase of the brain after the seventh year is 

1 The development of the senses is described in Part I, chapter on the "New-born 
Infant/' 



PLATE XXII 




Front View of the Foetal Skull, showing the anterior fontanelle and the 
coronal and frontal sutures. (Grandin & Jarman.) 



^ 



PLATE XXIII 




Top View of the Foetal Skull, showing the anterior fontanelle and the 
frontal, coronal, and sagittal sutures. (Grandin & Jarman.) 



PLATE XXIV 




Posterior View of the Foetal Skull, showing the posterior fontanelle and the 
lambdoidal and sagittal sutures. (Grandin & Jarman.) 



REFLEXES. 779 

due to an increase in the thickness of the cortex and in the size of the 
cortical constituents. 

Difference Bel ween Infantile and Adult Brain. — The fissure of Sylvius 
in its relation to the spherio-parietal and squamous sutures occupies a 
higher position in childhood than in later life. Symington and McClellan, 
in studying frozen sections of the brain of children under 7 years of age, 
found the Sylvian fissure above the squamous suture and covered by the 
parietal bone. 

Fissure of Rolando. — The position is the same in the infant as in the 
adult. 

The Cerebellum. — This is much smaller in the child than in the adult 
in comparison with the cerebrum. 

The convolutions of the train are more shallow in the infant than in 
the adult. The depressions or sulci between the convolutions are not so 
deep in the infant as in later life. The special centers of the brain are not 
fully developed in the infant (Taylor and Wells). 

Eeflexes. 

Excess of Reflex Action. — In acute mania, in cerebritis, and in acute 
meningitis we have excessive reflex action. In chronic hemiplegia an in- 
crease of the reflexes associated with ankle clonus is found on the affected 
side. In hydrophobia, transverse myelitis, insular sclerosis, and in tetanus 
we have an exaggeration of superficial and deep reflexes. Attention is 
directed to the chapters on "Tubercular Meningitis" and "Epidemic Cerebro- 
spinal Meningitis" for clinical illustrations of the reflexes. 

Diminution of Reflex Action. — The reflexes are lessened and sometimes 
absent in melancholia. Extreme pressure in the cranial cavity or in the 
spinal canal will reduce the reflex act. Whenever a degeneration of mus- 
cles or nerves takes place, such as in diphtheria or other specific diseases, the 
reflexes will be lessened. The reflex is reduced or wanting in acute anterior 
poliomyelitis. 

Babinshi Reflex. — In the new-born baby this reflex has frequently been 
noted under normal conditions. Instead of normal flexion of the toes, 
which is accomplished by irritation of the soles of the feet, we have in dis- 
ease a hyper extension of the great toe. This symptom is regarded as 
pathognomonic by some authors. I have frequently found this symptom 
present in tuberculous meningitis, and regarded it as a valuable diagnostic 
aid. (See clinical case, article on "Tubercular Meningitis.") 

Reaction of Degeneration. — "In health a faradic current of sufficient 
strength applied to the nerve produces a continuous contraction of the mus- 
cle; the galvanic, a momentary contraction when the current is made and 
broken only. When the nerve is diseased a stronger faradic or galvanic 



780 DISEASES OF THE NERVOUS SYSTEM. 

current is needed to produce contraction, until finally, when degeneration 
has taken place, no current which can be used produces any contraction. 
In health either current applied to the muscle produces contraction: the 
response both to the galvanic current and to the faradic is quick, being in 
both instances due to stimulation of the nerve-endings. "With lesion of the 
nerve and consequent degeneration of the nerve-endings, the faradic cur- 
rent produces no contraction, but since the galvanic current is capable also 
of stimulating the muscle libers themselves, a contraction follows appli- 
cation, though more slowly than when the nerve-endings are healthy. After 
the degeneration has progressed to a certain stage, which is reached the 
earlier the more severe the case, this response of the muscle fibers to the 
galvanic current becomes more ready than in health. To this quantitative 
change is added a qualitative change. In health the weakest galvanic cur- 
rent which causes contraction of the muscle does so when the current is 
made with the negative pole on the muscle (kathode closure contraction, 
K. C. C). When the nervous mechanism has degenerated a contraction 
may occur with as weak or with a weaker current when the positive pole is 
on the muscle (anode closure contraction, A. C. C), and contractions may 
occur also with the same current when it is broken (anode opening contrac- 
tion. A. 0. C, and kathode opening contraction, K. 0. C. 1 ). To this 
altered qualitative and quantitative reaction of nerve and muscle to the 
electric currents the term "reaction of degeneration"' is applied. It is not 
always as definitely marked as is above described. When the damage to 
the nerve is slight, the irritability of the nerve to both currents may be 
retained, and the only evidence of the existence of a reaction of degenera- 
tion is increased muscular irritability to the galvanic current, with some 
change also in the order of contraction to the poles (qualitative change). 
On the other hand, in very chronic changes the loss of irritability proceeds 
pari passu in nerve and muscle, and the reaction of degeneration is not to 
be observed. 

"With the regeneration of the nerve, recovery of function takes place, 
the rate of recovery depending mainly on the severity of the lesion. Vol- 
untary power is first regained, then the galvanic reactions become normal, 
and lastly, the faradic. 

" Anaesthesia, which is the eventful result of degeneration of a sensory 
nerve, may be preceded by a condition of hyperesthesia. The anaesthesia is 
often incomplete, especially in the hands and face; in a mixed nerve a 
lesion, capable of producing paralysis of motion, may be accompanied by 
little loss of sensation. Trophic changes seem seldom to occur in children 
as an accompaniment of lesions of sensory nerves." 



»The normal order is: K.C.C., A.C.C., A.O.C., K.O.C. 



CHAPTER II. 

CONVULSIONS E< LAMPSIA). 

- KS ecur mostly in infancy. After the seventh year of life 
they are very rare. The brain grows more during the first year than in all 
later life. This rapidity of growth is in itself, according to some w: 
an important predisposing cause of functional derangement. 

Etiology. — The Excitin s. — The predisposing causes may be 

grouped under the name of "central." They are : — 

1. Diseases having a high temperature. 

••?. Diseases :>mpanied by vascular stasis. 

3. Diseases cha] 1 by anaemia and exhaustion. 

4. Toxic cans 

Organic central lesions. 

6. Functional disturbances of the brain, such as epilepsy. 

Of all the manifold predisposing causes of convulsions in young chil- 
dren, the most important one is the natural instability of the nervou- 
ters. characteristic of early life, and associated with the non-developme:-.: : 
voluntary centers of the cortex: hence it is that age is a most important 
factor in the etiology of convulsions: and under 2 years is recognized as 

r the most susceptible period. Statistics show that over 60 per 
of deaths from convulsions, up to 21 :-. occur in infants under 1 year 
of age. Convulsions are not only more common in infancy, but much 
more fatal than later in life, and for reasons that are very apparent. It 
has been stated by some good observers that males seem to be more bus 
tible than female-: statistics seem to justify this conclusion, but it has 
been suggested by others that inasmuch as more males than females are 
born each year, the larger number of deaths in males may thus be recon- 
ciled, for surely it would be contrary to reasonable expectation, as females 
are more delicately organized, while the exciting causes are probably about 
equal. 

pheral C m 9. — The peripheral causes are rachitis; s 
disturbances, such as acute catarrhal gasti - intest : 1 worms: foi _ 
bodies in the ear and nose, causing reflex convulsions : scalds and burns. 
and mental disturbances, such as fright, will induce convulsions. Lewis 
••'Connusions are in all probability due to an exaltation of the lower 
nerve-cen: more frequently, to a suspension of the inhibit 

of the higher cerebral centers" — or both of these conditions mav exist at 

(781) 



782 DISEASES OF THE NERVOUS SYSTEM. 

the same time — and further, "It remains to be said that we are still very 
much in the dark as to the immediate processes producing convulsions." 

"Infants have their nervous system in process of rapid development — - 
only the component but undifferentiated parts of which are in great activity, 
ready to receive and re-energize limitless new impressions." At birth, the 
lower centers only are developed, and control is limited until the higher 
centers become competent to exert inhibition; hence in the earlier months of 
life convulsions are common, and less so after two years. 

Improper feeding may be looked upon as the most frequent cause of 
convulsions. A child that is improperly fed and surfers with a subacute or 
chronic form of dyspepsia, suffers with a deficient structure. Such struc- 
tural weakness resulting in rachitis, is a cause for that most common form 
of spasm known as laryngeal spasm and tetany. Toxasmic conditions re- 
sulting from bacterial infection are a most frequent cause of convulsion. 

Pathology. — The development of the nervous system is not complete 
at birth. Very little light is shed upon convulsions by post-mortem findings. 
Usually after death from convulsions there is an effusion or haemorrhage 
found or there is a venous stasis in the brain. When death occurs from 
laryngospasm it results from suffocation. The condition of the brain in 
the beginning of an attack of convulsion is one of anaemia. This is shortly 
followed by a nervous hyperemia. The brain and meninges are usually 
found intensely congested and engorged. Sometimes punctate hasmorrhages 
can be found. The lungs are also deeply congested and the right heart is 
generally distended with dark clots (Holt). 

Symptoms. — There is usually a loss of consciousness. The onset is 
sudden. A child may appear perfectly well up to the time of its convulsion 
and then suddenly the arms and legs become stiff, the eyes fixed and staring 
or rolled up under the lids. Eespiration is usually arrested, the head is 
retracted; finally the whole body becomes rigid. 

The above named symptoms belong to the tonic stage. It is usually 
followed by clonic convulsions more or less severe and prolonged, affecting 
the upper and lower limbs, the face and eyes. 

Sometimes the tonic and clonic convulsions are few and the whole 
spasm may last less than a minute. Some children show no sign of illness 
after the attack is over, and appear perfectly normal. The attack may recur 
at short intervals. The child may then become comatose and die before 
proper treatment can be instituted. It is important to examine the urine. 
The possibility of a nephritis should not be overlooked. 

Diagnosis. — It is usually very simple to differentiate from epilepsy, 
which is most frequent after the third year. 

Convulsions usually are the first symptoms of the invasion of an acute 
disease. Scarlet fever, pneumonia, malaria, gastritis, and meningitis may 
be ushered in with convulsions. Measles is sometimes preceded by convul- 



CONVULSIONS. 783 

sions. Pertussis in which there is cerebral congestion may cause convul- 
sions. Bronchitis, membranous laryngitis, and laryngismus stridulus are 
sometimes preceded by convulsions. Do not suspect teething or worms as 
a cause of convulsions until all other causes have been eliminated. 

Treatment. — The treatment of convulsions consists of controlling the 
spasm. Inhalations of chloroform or sulphuric ether should be cautiously 
used, regardless of the age of the infant, until convulsions cease. 

Chloral hydrate and bromide of sodium, with some starch water, should 
be injected into the rectum; 5 grains each of chloral and bromide with a 
tablespoonful of starch water should be used and repeated every hour until 
the spasms are controlled. Leeching by the application of one or two 
leeches behind the ears is valuable to relieve cerebral congestion. We can 
also drain blood from the frontal sinus by the application of one or two 
leeches at the ahe nasi. A mustard foot-bath should likewise be used until 
hyperemia of the skin is produced. While the feet are suspended in 
mustard water an ice-bag or a cold cloth shonld be applied to the head. 

A child, 4 years old, was suddenly seized with convulsions, clonic and tonic 
spasms involving the face, arms, and legs. From the history I learned that the 
child had overloaded its stomach, was very feverish, and thirsty. A mustard foot- 
bath was ordered and a rectal injection of: — 

I£ Sodium bromide 10 grains 

Chloral hydrate 5 grains 

was injected into the rectum with two tablespoonfuls of thin starch water. 

One or two inhalations of chloroform were given to relieve the convulsions. 

The diagnosis of acute catarrhal gastritis was made and the convulsions 
attributed to a general toxaemia. When the convulsions ceased the stomach was 
washed with two quarts of warm water to which two tablespoonfuls of salt had been 
added. Food was discontinued and an interval dose of: — 

Ifc. Sodium bromide 5 grains 

Chloral hydrate 2 grains 

was given every hour until the child was in a deep sleep. Twelve hours after the 
convulsions first began, thin soup and broth were ordered. The child was well in 
two days. 

To control convulsions : — 

B Sodii bromidi 5 grains 

Chloral hydrate 5 grains 

Starch water 1 tablespoonful 

Mix thoroughly and inject, if possible, into the colon, through a small rubber 
catheter. Repeat every hour until convulsions cease. 



Lumbar puncture, the technique of which I describe elsewhere, is one 
of our most valuable therapeutic measures. By withdrawing 20 to 30 cubic 
centimeters of cerebrospinal fluid, I have seen marked benefit therefrom. 
The intracranial pressure which was relieved by this procedure, lessened the 



7^4 DISEASES OF THE NERVOUS SYSTEM. 

irritability of the child and promoted sleep. In a case of auto-intoxication 

;• gastric fever, with a temperature of 105 e F. and over, in a child 
about eighteen months old suffering with continued convulsions, the follow- 
ing rdei >J Treatment was carried out: First, a colonic flushing to empty 
the bowel: second, a tepid pack over the thorax: third, a lumbar puncture. 
withdrawing about 25 cubic centimeters of colorless cerebrospinal fluid; 
fourth, a diet of whey, and plenty of water was followed by an amelioration 
of all the symptoms. 

Headaches. 

Various forms of headache are encountered in children. As a rule 
reliance can be placed on headaches complained of J>y young 
children. There are four kinds of headaches which are most frequently 
seen in older children: — 

1. Pierlex headache. 

2. Headache due to general systemic cause. 

3. Headache of local origin. 

4. Headache due to brain lesions. 

Reflex Headaelie. — In chlorotic girls or in anaemic children headache 
is a common symptom. During menstrual disorders girls will usually com- 
plain of headaches. 

Hundreds of cases of headache due to eye strain have been seen by 
me in school children. These children complain of headache during and 
after school hours. The headache disappears during the night and the 
children never complain of headache in the morning. Most of these cases 
have been referred by me to an oculist, who as a rule hnds astigmatism. 
The treatment consists in relieving the eye strain by wearing eyeglasss. 

Headache Due to General Systemic Causes. — Headache due to auto- 
intoxication resulting from impacted faeces is frequently encountered. 
Rheumatic children and children of gouty parents frequently complain of 
headaches. Such headaches are frequently found in lithaemia. The gen- 
eral constitutional treatment consists of a diet of vegetables, and fruit. 
Xo meat should be given. Five to 15 grains of citrate of potash will 
usually benefit this condition. A laxative should always be given if head- 
ache is due to constipation. Exercise and outdoor play will aid this 
condition. 

Headache Due to Local Origin. — Children frequently complain of 
headache which is due to intra-nasal neoplasms. At other times such local 
causes as supra-orbital neuralgia, due to neuralgia of the fifth cranial 
nerve, will cause an intense headache. In the latter instance gentle mas- 
sage or a mild current of faradic electricity will relieve. In severe cases the 
internal administration of 1 / SOQ grain of Duquesnel's aconitia. three times 
a day, will relieve. In persistent headache it is advisable to have the ears 



SPASMUS NUTANS. 785 

carefully examined by a competent aurist. The frequency of middle-ear 
disease should be borne in mind. 

Headache Due to Brain Lesions. — In older children headache of a 
persistent character, associated with vomiting, should always be looked 
upon as suspicious of cerebral trouble. A case of this kind is reported by 
me in the chapter on "Cerebrospinal Meningitis." In older children Buf- 
fering with persistent headache it is advisable to examine the fundus of 
the eye to see if a choked disc is present. In one of my cases a tumor of 
the cerebellum was diagnosed in this manner. 

Migraine (Sick Headache: Hemicraxia). 

This is a headache confined to one side of the head, associated with 
dizziness and generally vomiting. 

Causes. — Overworked school children of a nervous type usually have 
these attacks. Children suffering with dyspeptic attacks are more fre- 
quently the victims of migraine. An indoor life in a crowded apartment 
will cause this condition. Eye strain is frequently the cause. 

Treatment. — Have the eyes examined and correct any abnormality, if 
present. The diet should be regulated and a laxative dose 10 to 20 grains 
of phosphate of soda should be given. The value of bromide of soda in 
Seltzer water, with or without caffeine, should be remembered. 

Spasmus Xutaxs. 

This condition is frequently associated with rickets. It is characterized 
by an involuntary and uncontrollable head shake. 

Etiology. — It may be associated with or follow traumatism. Fright 
and other psychical disturbances may cause this condition. Heredity plays 
an important part in its development. It is usually found associated with 
rickets. In a case of mine presented to the Section on Pediatrics of the 
New York Academy of Medicine, 1 spasmus nutans was associated with 
sporadic cretinism. 

Symptoms. — In some cases we see a continuous nodding, in other cases 
the motion is rotary. In rare cases both motions, nodding and rotary, may 
co-exist. Nystagmus, which is a movement of the eyes, rhythmical and 
oscillatory, either vertical or horizontal, may also be present. 

Prognosis. — This depends on the cause of the same. As a rule the 
prognosis is good. 

Treatment. — If rickets is the cause give the child anti-rachitic treat- 
ment. If it is associated with cretinism, as in the case reported by me, 
then give thyroid treatment. A change of air and general restorative treat- 



1 See Proceedings of New York Academy of Medicine for 1904. 

oo 



786 DISEASES OF THE NERVOUS SYSTEM. 

ment is also beneficial in these cases. Electricity is not indicated and 
should not be used. Massage may be tried. 

Stammering and Stuttering. 

This is due to a want of coordination among the muscles concerned 
in articulation. The trouble may be confined to the lips and tongue, or 
there may be a laryngeal spasm, causing difficulty with the vowel sounds. 

Stuttering is usually due to an affection of the neuro-muscular mech- 
anism of articulation proper; besides, the respiratory muscles are usually 
involved (Williams). Defects of speech may be hereditary, although a 
neurotic element may be found in children of neurotic parents. 

I have seen a severe type of stuttering in a child 4 years old, whose father was 
alcoholic. Another case I recall was seen as a sequela to septic scarlet fever. 

As a rule it is associated with some anatomical or pathological lesion 
in the naso-pharynx. 

"Difficulty with the explosive consonants is the commonest form, but 
both this and other forms only become serious affections when combined 
with irregular action of the muscles of respiration. In such cases, during 
the attempt to breathe, spasm of the muscles of the face, arms, and trunk 
may occur and increase greatly the distress which the patient suffers." 

Treatment. — Systematic instruction in breathing and speaking by a 
competent teacher. During singing, if attention is directed to breathing, 
the defect is absent. Persistent treatment by a very patient teacher will 
usually modify and benefit this condition. Medication is useless unless the 
child is weak and requires building up. 

Chorea (St. Vitus' Dance). 

This is a neurosis characterized by irregular involuntary movements 
of the muscles. It usually affects the muscles of the extremities, face, and 
tongue. As a rule these movements are not present when the child sleeps. 

Etiology. — As a rule this disease is most prevalent between the ages 
of 7 and 14 years. Chorea generally occurs in bright precocious children. 
It is seen more than twice as frequent in girls as in boys, and the dispro- 
portion becomes even greater after puberty. It is extremely rare in dark- 
skinned races. Chorea rarely becomes chronic, although it recurs in about 
one-third of the cases. It is more likely to recur in girls. 

Steven Mackenzie 1 reports 439 cases. The largest number of 8 tacks 
occurred in the thirteenth year. 

34 per cent, occurred between 5-10 years 

43 per cent, occurred between 10-15 years 

16 per cent, occurred between 15-20 years 

1 British Medical Journal, February, 1887. 



CHOREA. 



787 



Sachs reported a case seen in a child under 1 year of age, and several 
cases seen in children between 2 and 3 years of age. The reported con- 
genital cases are usually mistaken instances of organic cerebral disease. 

Sinkler found that of 328 cases, 232 were females, and 96 males. 
Gowers studied the statistics of 1000 cases and found 365 in boys and 635 
in girls. 

Morris J. Lewis, of Philadelphia, studied 717 cases and found that 
the largest number occurred in March, the next largest number in May, 
and that the curve corresponds with the rheumatism curve. 

My own experience is that we have an equal number of cases occurring 
in the spring and fall depending on the amount of study and the sedentary 
life induced by too much school. 

In a large children's service among the poor tenement population, out 
of 100 cases of chorea examined by me 80 cases occurred in females; 20 
cases in males. 

All of my cases were school children who were apparently well when 
their chorea commenced. 

Overstudy in School. — Sturges, in London, has given considerable at- 
tention to the question of overstudy, and he believes that it is an impor- 
tant etiological factor in the causation of this condition. Overstudy (ap- 
parent) may mean only inability to study due to lack of mental concen- 
tration. 

Chorea frequently follows the infectious diseases. It is seen after 
scarlet and typhoid fever. I have seen chorea of a very severe type follow 
a fright and also after bad dreams, in school girls. Keflex causes, such as 
phimosis, pin worms, and delayed menstruation, are cited by some authors. 

Reflex Causes Due to the Eye. — I have usually sent children suffering 
with chorea to the eye specialist to see if improvement could not be ob- 
tained by using eye-glasses. I believe that headaches due to astigmatism 
can be relieved, so also can astigmatism be modified when suitable glasses 
are prescribed. I do not believe that the chorea per se was cured in a 
single case. I do not refer to those cases of habit spasm so frequently seen 
in nervous children, but 1 refer to distinct chorea. 

A series of cases of chorea were under the treatment and observation of 
Dr. Herman Jarecky at the Manhattan Eye and Ear Hospital. He re- 
ported no improvement directly due to the wearing of eye-glasses. 

Reflex conditions, such as adenoids and polypoids, have been reported 
from time to time. 

The reflex causes are overestimated. Adenoids are more likely to in- 
duce tics rather than chorea. 

Neurotic make-up plays a distinct predisposing role (neuroses or psy- 
choses in family), 



788 DISEASES OF THE NERVOUS SYSTEM. 

Table No. 101. — The Association of Chorea with Rheumatism. 

Steiner reports 252 cases 4 suffered with rheumatism 

Sachs reports 70 cases 8 suffered with rheumatism 

Sinkler reports 279 cases 37 suffered with rheumatism 

Crandall and Holt report. . 146 cases 63 suffered with rheumatism 

Fischer reports 100 cases 25 suffered with rheumatism 

Twenty-five Per Cent, of my Cases had Undoubted Rheumatism. — 
By rheumatism I include cases that complained of pains in or around the 
joints. At times they were described as "growing pains" by the parent. 

Frequency of Endocarditis. — Valvular lesions have been seen by me 
in chorea without any antecedent joint lesions. The ease with which rheu- 
matism is overlooked in children makes the clinical history as given by 
parents doubtful. It is, therefore, possible that there are many more cases 
of rheumatism associated with chorea than are reported. 

Association with Tonsillitis. — Of the 100 cases of chorea previously 
reported by me, more than 80 cases had enlarged tonsils. It seems quite 
probable that the tonsil is the point of entrance of the pathogenic bacteria 
which cause chorea, and most probably rheumatism and endocarditis. 

Pathology. — There are no distinct pathological lesions which can be 
attributed to chorea. Sachs says that the pathology of chorea is still a 
great mystery. Not that autopsies are wanting, but there have been so many 
different post-mortem findings described that each writer may be said to 
have his own views concerning the pathology of chorea. 

Symptoms. — Chorea usually begins with prodromal symptoms. The 
children as a rule are very irritable, depressed, and cannot hold their arms 
or legs quiet. They complain of pain in various parts of the body. The 
main symptoms which attract the attention of parents or nurses are motor 
disturbances. These consist of involuntary twitchings affecting various 
muscles or groups of muscles. The muscles of the hands, the legs, the facial 
muscles, and the tongue show this choreic twitching. At times there is a 
decided interference with speech. A point worth noting is that the child 
cannot control these movements voluntarily. The greater the effort to con- 
trol these movements, the more the twitching will be noticed. Sachs em- 
phasized the fact that in doubtful cases choreic movements of the tongue 
will often prove the nature of the disease. This I have frequently been able 
to verify when it was a question of habit spasm or true chorea. There is a 
certain awkwardness which is typical in a choreic patient. This can be 
noticed when the child attempts to do anything. Choreic movements do 
not occur as a rule in the night when the child sleeps. The pupils are fre- 
quently dilated. Children are sometimes punished at school for restlessness 
which is the beginning of true chorea, and it is only later in the disease that 
the true character of the same is detected. In some cases but one-half of 
the body (hemi-chorea) is affected. In other cases choreic movements are 



CHOREA. 



789 



stronger in the upper than in the lower extremities. Children seem to 
suffer muscular weakness and there is loss of muscular power. A peculiarity 
of chorea is that in spite of the constant muscular twitching there is little 
exhaustion. The reflexes show no abnormality. 

Condition of the Heart. — Very frequently a systolic murmur has been 
heard during the course of chorea. This systolic murmur persists for months 
after the last symptoms of chorea disappear. Pains in the large joints are 
frequently described. I have invariably noted a slight rise in the tem- 
perature (101° F.) when the joint pains or endocarditis existed. When 
chorea appeared without evidences of cardiac or arthritic complications the 
temperature invariably remains normal. 

Fannie S., 11 years old, was a very anaemic girl. She had been sick for two 
months with tonsillitis and influenza. She was compelled to stay away from school, 
and in order to catch up with her class, studied very hard, especially at night, until 
she passed her examinations. 

History Given by Mother. — The child complained of headache, her appetite was 
poor, the bowels constipated. She was restless by day and did not sleep well at 
night. She had nervous twitchings of the arms and legs. The fingers were never 
still. She did not appear contented at anything. Her eyes were examined by an ocu- 
list, who prescribed eyeglasses. He said the child had eye strain. The mother 
believed there was a slight benefit after wearing the glasses. 

When the child was brought to me, there were distinct evidences of chorea, with 
twitchings of the face, the tongue, the hands and the legs. Four drops of Fowler's 
solution was prescribed, three times a day, and gradually increased until 7 drops were 
given three times a day. All school and study was stopped. Cold sponging and a 
cold shower was ordered every morning and evening. Cereals, vegetables, milk, and 
fruit were given. All meat was stopped. An active outdoor life and all quiet games 
and sports were recommended. Under this treatment the symptoms gradually sub- 
sided and the child recovered. One year later the same symptoms returned, and it 
was found that the cause of the relapse was overstudy. I prescribed "remove the 
cause," namely, take the girl away from school. 

Course. — The usual course of this disease is from six to ten weeks, 
although it may extend to four months. I have seen cases in which there 
was a severe attack in the spring, which seemed to disappear entirely dur- 
ing the summer, and suddenly reappear with greater intensity in the fall. 

Prognosis. — The outcome of a case of chorea is usually good, especially 
so if we are dealing with intelligent mothers and nurses. The prognosis is 
bad if endocarditis or other organic lesions are associated. 

Treatment. — Rest Treatment. — It is useless to attempt to modify se- 
vere or mild chorea without enjoining absolute rest in bed. The eyes should 
be protected from a strong light, or the room should be darkened by drawing 
the shades. In some cases I have kept children in bed for one week before 
the twitchings ceased. In severer cases it may be necessary to keep a child 
in bed at least two or more weeks. The soothing influence of this absolute 
rest in bed will do more good than all the drugs combined. 



790 DISEASES OF THE NERVOUS SYSTEM. 

Hygienic Treatment. — A child should be removed from school and 
thus guarded against all psychical disturbances. Cold sponging of the en- 
tire body and cold spinal douches have been found very beneficial. 

The diet should be light and very nutritious. All cereals should be 
given (see diet list for a child from 3 to 10 years old, page 154). Meat 
should be avoided, although meat soups and white meat or chicken may be 
permitted. Later fresh air and quiet out-of-door exercise, games, and sports 
are necessary adjuncts in the treatment of this disease. 

Medicinal Treatment. — Iron and arsenic should always be remem- 
bered in the treatment of this disease. We can begin with 4 or 5 drops of 
Fowler's solution, three times a day, and watch the systemic effect, with 
gradually increasing doses until 10 drops, three times a day, are given. 
Great care should be used to avoid arsenical poisoning when large doses of 
Fowler's solution are given. In some children a peculiar idiosyncrasy 
exists which renders them liable to systemic poisoning. Semple has re- 
ported multiple neuritis following the use of arsenic in the treatment of 
chorea. I have seen multiple neuritis in a- rachitic child having chorea 
minor. The child received 4 drops of Fowler's solution for six weeks. 
When the arsenic was withdrawn, the neuritis subsided. Of the prepara- 
tions of iron on the market, neoferrum in doses of 1 or 2 teaspoonfuls has 
served me very well. Another preparation which I have frequently used is 
the liquor ferri peptomangan (Gude) in doses of a teaspoonful, three times 
a day, after meals. Ferratin, 5 to 10 -grain doses, three times a day, after 
meals, is also beneficial. Antipyrin and bromide of sodium may also be 
used in some cases. When chorea is associated with rheumatism, the salicy- 
late of soda in 3 to 5-grain doses, or salipyrin in the same quantity, may 
be given three or four times a day. Some authors advise against the use 
of chloral hydrate; my personal experience with 2-grain doses of chloral 
hydrate given morning and evening has been very good. If choreic twitch- 
ing does not improve after several weeks of persistent treatment, then a 
cold pack may be tried. A sheet wrung out in cold water at a temperature 
of 60° F. should be wrapped around the child for one hour every morning 
and evening. Not only have I seen a soothing effect on the nervous system 
from these packs, but they frequently promote sleep. That electricity is of 
value in this condition is doubted by many. I have seen one or two cases in 
which excellent results were obtained from the use of a weak galvanic cur- 
rent over the spinal nerves. On the other hand I have frequently seen no 
effect whatsoever from the treatment with mild or strong galvanic currents. 

Sachs recommends hyoscyamin in tablet form, 1 / 100 grain, when rest- 
lessness and insomnia exist. Hyoscyamin should only be administered in 
the afternoon and evening. Massage is sometimes of value in conjunction 
with electricity ; it has a soothing effect on the nervous system and stimu- 



HYSTERIA. . 791 

late* nutrition. It is especially valuable at night and 1 have seen a pro- 
found Bleep follow thorough massage of the body. 

Hysteria. 

It is an important matter to recognize this condition when met with 
in children. It is rarely seen in children under 7 years of age, although 
cases are on record of distinct hysteria having been met with in infancy. 
In my experience children rarely simulate disease. I have seen children 
imitate an invalid mother and complain of imaginary pains and aches at 
the same time and in the same portions of the body as the mother. Very 
neurotic children, susceptible children, and children having bad habits, such 
as masturbation, are more prone to develop hysteria. Charcot maintained 
that hysterical persons are hysterical because they are mentally degenerate. 

Pathology. — Hysteria is not a fatal disease, hence we have no specific 
pathological lesions. The theory concerning the mobility of the neuron, 
while very interesting and scientific, does not explain the hysterical par- 
oxysms. Hysteria is not a psychosis as is generally supposed. There are no 
known demonstrable lesions. While in some cases the whole brain seems 
disturbed and involved, in other cases but one-half of the brain is involved. 

Symptoms and Diagnosis. — Paralyses occur in hysteria which simulate 
those due to central nervous disease. As a rule, however, they disappear. 
The hysterical paroxysm usually follows close upon an aura. It sometimes 
comes on suddenly, although it may be preceded by a spell of laughing or 
crying. Children old enough to complain describe a "lump in the throat" 
similar to the "globus hystericus" which occurs in the adult. 

fSome symptoms closely resemble epilepsy. Headache is complained 
of at times. The screaming and shouting gradually cease as the attack 
subsides. The following description given by Taylor and Wells describes 
the attack so closely that I repeat it: "The patient sinks down or falls 
prone upon the back, with the limbs extended and rigid, but with the fingers 
and toes flexed; the eyes are usually rolled slowly from right to left, or 
crossed; the jaws are firmly closed; the breathing becomes slow and 
labored, and later hurried, the face flushed or bluish, the neck turgid; the 
cardiac action becomes more rapid and forcible, and consciousness is 
almost, but never entirely, lost. Sensation is much obtunded, and abolished 
in some portions of the body. Soon clonic movements succeed — a tremor 
affecting the muscles of the trunk, extremities, and face. This alternates 
with electric-like startings, during which the patient may fling himself 
furiously about, or actually out of bed. Presently this stage ends with 
sighs, and is followed by a short sleep." Some authors describe a series 
of dramatic movements. There may be opisthotonos. The child may have 
a bowing of the lumbar curve so that it rests upon its head and heels. 



792 DISEASES OF THE NERVOUS SYSTEM. 

There may be a series of attacks recurring so that as many as two hundred 
paroxysms have been recorded by Sachs. I have seen a severe form of 
hysteria with over ten paroxysms during one hour. Some tender areas 
frequently noted in children, over the ovaries and spine in girls, and the 
testicles of boys, are very sensitive. Some authors claim that pressure over 
these areas will sometimes invite an attack of hysteria; on the other hand 
pressure over these same sensitive areas will sometimes stop an attack. 

Vomiting when it does occur is a very serious symptom. We do not 
have the same forms of tremor as are seen in adults. 

Borborigmus (rumbling gas in the intestines) is occasionally heard in 
this condition. 

Epidemics of hysteria are frequently described. J. Madison Taylor 
describes one occurring in a church home at Philadelphia. I have fre- 
quently seen children in one locality suffer with various manifestations of 
hysteria, in which we could easily trace the origin to one particular child. 

Prognosis and Course. — The duration of the disease depends on the 
surroundings of the child. Mild hysteria will sometimes disappear after a 
change of scene and air of several weeks. In some instances a case may 
last years or through the child's whole life. 

It is always well to remember that hysteria is difficult to cure. If a 
child is sensitive and subjected to impressions from a neurotic family, then 
a cure will be difficult. The outcome of any case of hysteria depends on 
the character of the surroundings and on the mental influences with which 
the child is brought in contact, rather than on drug treatment. 

Case I. — A girl 9 years old was brought to me for the relief of headache. She 
complained of a continual headache night and day. The appetite was poor, the 
bowels moved sluggishly. She was restless during the day, and had insomnia at night. 
She complained of bad dreams. She looked haggard and worn, as though she 
were convalescing from some severe illness. She was anaemic and had cold extremi- 
ties. Heart, lungs, liver, and spleen were normal. She was a very restless child with 
marked hypersesthesia. The patellar reflexes were exaggerated. 

Subjective Symptoms. — The child complained of pain in every part of her body. 
On being asked, "Does your side hurt?" she answered, "Yes, my pains are in the side 
and in the back, just like my mother's." I referred the child to an oculist for an 
opinion as to the eyes, and his answer was : nothing abnormal, no astigmatism. The 
child cried on the slightest provocation, and was also almost convulsed with laughter 
for trivial matters. The diagnosis was hysteria. The child had a headache, or a 
backache, and always complained of some ache. It was quite evident that the child's 
hysteria was due to suggestion by tlie mother, who teas an invalid. 

The treatment consisted in removing the child to an aunt in a neighboring city, 
amid healthy surroundings. Iron was ordered to build up the system, and bromide 
of soda in 10-grain doses was given every night for one week, later' every other night. 
Electricity, the baths, and massage were used with great success. In three months 
the child had rosy cheeks, slept well, was cheerful, and did not complain of any pain. 
It was strange, however, that when taken back to her mother, she immediately re« 



MULTIPLE NEURITIS. 793 

lapsed into her former habit oi complaining. We determined to remove her per- 
manently, and she remained well for over a year when I last heard of her. 

Task II. 1 — General Hysteria and Nervous Vomiting. — A girl 12 years old was 
brought to my children's clinic for the relief of vomiting. She was very nervous 
and complained of pains all over her body. She complained also of pains in her 
stomach before and after eating. Her mental condition was poor, the hands and 
feet were cold. She complained of epigastric pains for the last six years. From 
the mother I learned that the child was frightened by a dog and since that time she 
has been very sensitive to the slightest impression. The gastric contents were 
syphoned oft* after a test meal and a hyperchlorhydria was found. The urine con- 
tained acetone. 

The treatment of this case was most successful when large doses of bromides 
were given. 

Treatment. — Study the cause or causes, and remove them if possible. 
Change the surroundings of the child by removing to a cheerful but quiet 
home. If the case occurs in the country, bring the child to the city. In 
any event the main point should be to change the entire scene and sur- 
roundings. If a child is in an institution, remove it from the same if it 
is at all possible. The person in charge of the child should be either a 
very intelligent mother having a positive influence over the child, or a 
mild-mannered trained nurse. All orders of the physician should be 
strictly obeyed without having the child feel that vigorous treatment is 
being used. This psychosis requires educational treatment as has just been 
described. 

Hygienic Treatment. — If the child is old enough, a walk should be 
ordered several times a day. The bicycle and horseback are valuable ad- 
juncts. The sponge bath or the tub-bath aided by a cold shower or spray 
chiefly over the spine, head, and neck, have very tonic properties. 

Hydrotherapy properly used is one of the most valuable aids in pro- 
moting a cure. 

Xothwithstanding the shock of a cold spray, the same should be ordered 
winter or summer. 

After the bath the body should be rubbed vigorously, or better yet, 
massage should be given. I have always found a very soothing effect on 
the nervous system by giving gentle but thorough massage. Another reme- 
dial agent which must be used regularly is electricity. This should be used 
daily by means of a mild faradic current, one electrode to be applied over 
the spine, the other over the phrenic nerve. If no benefit is noticed after 
this treatment is tried, then static electricity can be used. 

Multiple Neuritis (Polyneuritis). 
This is frequently termed a peripheral neuritis, as it is an affection 
of the terminal branches of the nerves. It usuallv affects all the nerves 



1 This case was presented by me to the Section on Pediatrics, Academy of 
Medicine. Februarv 14, 1901. 



794 DISEASES OF THE NERVOUS SYSTEM. 

of the limbs on both sides of the body. Starr gives the following classifica- 
tion : — 

"1. Toxic cases due to the action of a poison derived from without 
the body. These poisons are alcohol, carbonic oxide gas, bisulphide of car- 
bon, the coal-tar products, especially sulphonal and trional; and nitro- 
benzol; also, arsenic, lead, mercury, copper, phosphorus, and silver. 

"2. Infectious cases due to some agent acquired or developed within 
the body, as an accompaniment or sequel of diphtheria, grippe, typhoid, 
typhus, malaria, scarlet fever, measles, whooping-cough, smallpox, erysipe- 
las, and septicemic conditions, including gonorrhoea and puerperal fever, 
epidemic forms of beriberi or kakke, and leprous neuritis. 

"3. Cases due to general diseased states of the body whose origin is 
undetermined, such as rheumatism, gout, diabetes, anaemia, marasmus, gen- 
eral malnutrition consequent upon tuberculosis, syphilis and senility, car- 
cinoma, and local malnutrition produced by arterial sclerosis. 

u 4z. Cases due to exposure to cold and developing spontaneously with- 
out known cause."* 

The most common type of multiple neuritis met with in children is 
either the diphtheritic type or that resulting from poisons in the blood, 
such as the prolonged administration of Fowler's solution (arsenical poi- 
soning). 

Symptoms and Diagnosis. — Multiple neuritis may come on suddenly 
or the onset may be gradual. The special senses are rarely involved in 
this condition. The motor symptoms are as marked as the sensory. Paral- 
ysis comes on first as a muscle weakness, and gradually increases until dis- 
tinct paralysis is present. The extensor muscles of the wrist, hands, and 
feet give the wrist-drop and the foot-drop. Very rarely the muscles of all 
four extremities in addition to the muscles of the trunk and neck are in- 
volved. The knee-jerk usually disappears early when neuritis follows diph- 
theria. The paralyzed muscles are relaxed, flabby, and atrophied. An 
important symptom is that faradic excitability is absent and that the mus- 
cles respond to a galvanic current only. This symptom is identical with 
that found in acute anterior poliomyelitis. The reaction of degeneration is 
present. 

There is usually no incontinence of bladder and bowel. Atrophy is 
another prominent symptom. The condition is similar to that seen in 
poliomyelitis. There may be other vasomotor disturbances such as uni- 
lateral flushing of the skin, or small areas may show, a high glossy flush. 
This last symptom was very prominent in one of my cases. An oedema 
of the affected parts is described by some authors. As a rule the areas 
affected are very sensitive, so that we have distinct hyperesthesia. In other 
cases the opposite condition prevails and there are areas of local anaesthe- 
sia. The disease may be ushered in by a fever. The temperature may rise 



PAVOR NOCTURN1 B. 705 

to 103° or 104° F.j and remain several days. The pulse-rate is correspond- 
ingly increased and may reach 140 or 160. 

Gastric disturbances associated with diarrhoea may be present. The 
spleen is frequently enlarged, and an examination of the blood will show 
a distinct leucocytosis, the latter condition when neuritis is a sequela to 
an infectious disease. 

Course and Prognosis. — As a rule, multiple neuritis lasts from several 
weeks to several months, and then ends in recovery. The cases seen by me 
associated with chorea in which arsenical poisoning took place, invariably 
unproved when the drug was withheld for a short time. Rarely does the 
paralysis remain permanent. The prognosis can best be gauged by noting 
the electrical reactions. If the reaction of degeneration is present after 
the disease has lasted several months, then a permanent lesion must be 
suspected. If, on the other hand, there is only a slight difference in the 
reaction following the use of the faradic current, then a complete recovery 
may be expected. Some cases, although severely atrophied, will ultimately 
recover. If myelitis complicates this condition, the prognosis is serious. 

Treatment. — The system should be strengthened with proper nutrition. 
The patient should be made as comfortable as possible. If severe pains 
exist, then large doses of bromide should be given, with or without codeine, 
until all pain is relieved. In some cases the local application of warmth 
over the affected limb is very soothing. I frequently use a warm bath at 
night, which is very soothing and promotes sleep. 

Gentle friction and massage are beneficial. Restoratives, such as cod- 
liver-oil, maltine with hypophosphites, and iron should be used. The 
syrup of the iodide of iron is a good restorative. Butter, cream, and 
cereals are excellent tonics. Strychnine and nux vomica are valuable if 
the appetite is poor; otherwise they have no specific value. 



Pavor Nocturntts (Xight Terrors). 

Children apparently healthy will sometimes awaken from a sound 
sleep and shriek or scream. 

Etiology. — In this condition children usually show some disturbance 
of the stomach or bowels whi.ch may have been the exciting cause of the 
night terror. Reflex irritability is frequently caused by intestinal worms, 
by adenoid vegetation, or in the male child by an elongated prepuce, or 
by phimosis. Such children usually possess a neuropathic constitution by 
inheritance. Henoch states that some children may have hallucinations 
during the day. These attacks occur but once during the night, and after 
reassuring the child that there is no danger, it will again fall asleep. 

Symptoms. — Some children awaken frightened and screaming, while 
others w r ill grasp anything within reach in a bewildered manner. They 



796 DISEASES OF THE NERVOUS SYSTEM. 

frequently imagine that animals are in the room. The effect of too rigid 
discipline will sometimes show itself by bad dreams at night, and in a 
distinct hysterical symptom, such as fright and terror. 

Course and Prognosis. — If these night terrors are associated with mild 
nervous attacks during the day, or if they partake of the nature of epileptic 
attacks, then a cautious prognosis should be given. The inclination to 
serious brain or nervous trouble must always be remembered; therefore, 
no opinion should be ventured until a case has been properly observed. 

Treatment. — Children having night terrors should be removed from 
school to insure perfect tranquillity. There should be a distinct change of 
scene, a change from the city to the country, or vice versa, will be bene- 
ficial. Any reflex cause, if present, should be attended to, and, if possible, 
removed. Fresh air, out-of-door life, and restoratives are indicated. Such 
children appear less frightened if they sleep in the room with an adult, 
and are thus reassured that there is no danger present. 

Cold or gradually cooled bathing or a spray over the spine will tone 
the nervous system. It should be used in a warm room daily. Five grains 
of sodium bromide may be given before retiring. 

Masturbation ( nanism ) . 

This habit is very frequently seen in children. I have seen it in girls 
as well as in boys. 

Causes. — Any irritation of the genital tract that will cause itching 
may be the origin of masturbation. In boys an elongated prepuce, or 
friction from phimosis, may give rise to this condition. Very acid urine 
may cause excoriation and thus invite this bad habit. Excoriations at or 
near the external meatus may be the starting point. We see this condition 
quite frequently in girls when preputial adhesions due to smegma or dirt 
cause an irritation of the clitoris or when pin worms wander from the anus 
to the vagina; thus worms frequently set up an irritation resulting in mas- 
turbation. A diaper if too tightly pinned can set up an irritation, especially 
in female children. 

Symptoms. — Children usually place their hands on the genitals and 
masturbate. They sometimes rub their thighs together until exhausted. 
During this friction their face will be flushed and they appear irritable. 

Such children suffer with profound anasmia as the result of this habit ; 
and from loss of sleep. Older children, especially boys, will masturbate 
chiefly at bedtime. They are peevish, irritable, and very sensitive. 

An infant about nine months old was seen by me in consultation with Dr. L. 
F. Harris, of New York City. The mother complained that the child continually 
rubbed its thighs. The face was flushed during the rubbing; later the child would 
fall asleep as though from exhaustion. This condition seemed to occur chiefly when 



MASTURBATION. 797 

the child was placed on the bed or held on the lap. An examination of the genitals 
showed that they were very red and excoriated from the constant irritation. 

The prognosis is usually good if the habit is detected early and the 
cause removed if one exists. On the other hand, some cases will persist 
in spite of careful treatment, and nothing but heroic measures will effect 
a cure, as the following case will illustrate: — 

An infant, female, was brought to me for the relief of this condition. The 
child had masturbated continually for several months and was so emaciated that 
the parents were alarmed. The condition was so bad that the child masturbated 
whenever the thighs were put together. A pad was improvised to separate the thighs 
and local applications of lead water on cotton were placed over the genitals to reduce 
the irritation. Large doses of bromides were administered to control irritability in 
the nervous system. The child was kept in a stupor for several days without having 
the condition relieved. The symptoms persisted, and we finally were compelled to 
remove the child to the St. Marks Hospital where Dr. H. J. Garrigues suggested per- 
forming a clitoridectomy. This case was published ill extenao in Archives of 
Pediatrics. May. 1S99. The child made a perfect recovery. The habit did not 
reappear. 

Treatment. — Eemove the cause if any exists. All irritants, such as 
worms or eczema, should be treated. If an enlarged prepuce causes this 
condition, remove it. If a vaginal discharge exists, treat it with astrin- 
gents, and thus avoid irritation. If worms are present, injections of quassia 
will dislodge them (see chapter on "Worms"). In older children we must 
remove the child from bad company, and sometimes it will be necessary to 
change the entire surroundings of a sensitive but well-meaning child. An 
ocean voyage is beneficial. The system should be strengthened by giving 
iron and strychnine. Clean habits, a rigid hygiene, and a daily bath are 
necessary. Strict supervision by night as well as by day with the aid of 
a trained nurse will do more good than medicine. Children once detected 
with this bad habit must never be permitted to sleep with their hands under 
the bedclothes. 

Circumcision is one of the most valuable means of curing this habit. 
In females, especially in little girls, stripping the clitoris and cleansing the 
smegma, if present, will frequently modify this habit. If the habit persists 
in spite of this treatment, then a radical operation (see clinical case given) 
may be required. 



CHAPTER III. 
TETANY. 

Tetany is a nervous disorder characterized by tonic spasms, chiefly 
affecting the hands and feet. They are known as carpo-pedal contractions 
or sometimes as arthrogryposis. 

Etiology. — Intestinal toxaemia is presumed to be the etiological factor. 
Tetany is usually found in infants under 2 years of age. Laryngismus 
stridulus is frequently associated with it. 

It is intimately associated with rickets and with other diseases resulting 
from improper nutrition, such as athrepsia and dyspeptic conditions. It 
frequently follows diseases which exhaust the vitality of an infant, such 




Fig. 257. — Tetany. Characteristic attitude of the hands resembling a 
rider reining in his horse. Note attitude of the toes. The wrists are 
rigid and flexed. The elbows are free. The fingers are flexed at the meta- 
carpal-phalangeal joints. In this case facial irritability was best seen by 
constant spasm in the orbicularis palpebrarum. (Original.) 

as broncho-pneumonia, typhoid, or whooping-cough. It is very often noted 
when these diseases have lasted a long time. 

Facial irritability is not uncommon in older children, and it occurs 
with them not only in tetany and certain other nervous conditions, but 
with slight dyspeptic disorders, and sometimes apart from any ascertain- 
able disease. In young children it is common, but it is rarely, if ever, 
found before the sixth mc ath. It occurs in most cases of laryngismus. 
When met with alone in children under 3 years old who have any sign of 
rickets, it may, practically always, be regarded as a danger signal, showing 
a state of abnormal nervous excitability and a probable tendency to more 
serious neuroses. Under these circumstances, therefore, it must be taken 
(798) 



TETANY. 

D indication for prompt sedative, tonic, and especially antirachitic 
treatment. 

Symptoms. — If we tap the muscles of the jaw, a slight contraction of 
the face ensues. This is known as the faded phenomenon, and was first 
described by Chvoetek. The contractions are first se^n in the orbicularis 
palpebrarum. 

The contraction resembles that caused by the sudden passage of a 
galvanic current. It is sometimes more marked on one side of the face 
than the other: and. in some cases, it is more noticeable in the upper; in 
others, in the lower half of the face. A similar contraction of the inner 
end of the eyebrow may often be caused by tapping on the temple. The 
wrists are rigid and flexed. The elbows are free. The fingers are flexed 
at their metacarpophalangeal joints. There may be a constant spasm, 
jerking in character, continually present. 

A similar phenomenon is known as Trosseau's sign; if the arm is com- 
ssed by an elastic band the muscles of the fingers and sometimes of the 
forearm pass into the tetanic condition. 

Kassowitz maintains that laryngeal spasm is a symptom of tetany and 
that its occurrence is pathognomonic. 

Course. — The course of this disease is given by some authors as from 
a few days to several weeks. In one case observed by me at the Willard 
Parker Hospital ( see Fig. B57), the tetanic spasms lasted for more than two 
months. Other cases seen by me lasted but a few days or weeks at the 
long 

Prognosis. — The prognosis is excellent if the cause of the tetany is a 

>intestinal disorder. 

There are instances in which death has ensued from laryngeal spasm 
or from general convulsions. When a very frail infant has severe tetany 
of the upper and lower extremities with retraction of the head, then the 
prognosis is bad. 

ers repcv- - - of tetany followed by muscular atrophy. 

Treatment. — It is advisable to cleanse the gastro-intestinal tract by 
giving calomel from 1 / 2 to 1 grain, repeated if necessary.. Castor-oil is a 
safe remedy. Ehubarb and soda is also a good corrective. If the child 
is over 1 year old. then a wineglassful of citrate of magnesia will be useful. 

5 ' mach washing should nof be resorted to, as there is a risk of causing 
laryngeal spasm by this procedure. If the child cries owing to pain caused 
by the tetanic spasm, then chloral and bromide should be given. A xarm 
bath is generally well borne. Belladonna or atropine is useful when given 
in full doc - Salol and bismuth with calcined magnesia are very good 
intestinal antiseptics. 

^oid condition has been reported by Maestro after the extirpa- 



800 DISEASES OF THE NERVOUS SYSTEM. 

tion of the thyroid gland. For this reason the extract of the thyroid gland 
has been advocated for the relief of this condition. 

Teiaxus 1 (Lock Jaw). 

This acnte infections disease is caused by the invasion of a specific 
micro-organism. 

Etiology. — Any open wound on the surface of the body can be the 
point of entrance for these pathogenic bacteria. 

There are some parts of our country in which the disease exists all 
the year round, provided the factors which cause the same, filth and dirt, 
are brought into play. A child infected with tetanus can transmit the 
disease, hence this should be borne in mind while a case is under treatment. 

Bacteriology. — Xicolaier in 188-4 found a specific micro-organism in 
the soil from which he infected animals and produced tetanus. He also 
found this germ present in patients affected with tetanus. 

In 1898 Kitasato demonstrated this bacillus in pure culture. It was 
also found in infants suffering with tetanus. From the pure culture 
Kitasato and Behring produced an antitoxin. 

The toxin generated by tetanus is a deadly poison. Kitasato found 
that an animal which was infected and left alone died in one hour. 

Pathology. — Distinct lesions of tetanus cannot be demonstrated patho- 
logically. An open wound and evidences of a general septic infection can 
usually be found. Haemorrhages of the brain or smaller haemorrhages in 
various parts of the body may exist. If the umbilicus has been the point 
of entrance, the wound will not heal. 

Symptoms. — In the new-born the first symptom noticed is the refusal 
to take the breast. Owing to the rigidity of the muscles the jaws will be 
found stiffened and feel hard to the touch. The same spasmodic stiffening 
will be made out in the other parts of the body. After a sudden stiffening 
the muscles usually relax. Muscular rigidity appears in paroxysms and 
may come on every few minutes. 

The temperature varies between 101° and 104° F. or there may be 
hyperpyrexia reaching 107° F. The pulse is small, feeble, compressible, and 
very rapid. Symptoms of malnutrition, such as emaciation, are very evi- 
dent. Stadtfeldt reports 88 fatal cases; 83 of these died between the ages 
of six and ten days. 

The following case illustrates tetanus seen in private practice: — 

A. female infant fifteen days old was seen by me suffering with fever. The nurse 
said that she refused the breast. The infant was i: ?ood health apparently up to this 



1 Owing to the specific effect of the tetanus bacillus on the nervous system. I 
have purposely placed this article in the chapter dealing with lesions of the brain 
and nervous svstem. 



EPILEPSY. 801 

time. The appetite was good, the bowels regular, no gastric disturbances existed. 
On examination the umbilicus was found inflamed and suppurating. The temperature 

was 102° F. ; the pulse ltH). The jaws were fixed. The infant had spasms, which 
grew more severe W hen she was handled. The body relaxed for a few minutes at a 
time. 

The treatment consisted in cleansing the wound with strict asepsis, dusting 
europhen powder on the umbilicus, and protecting the same with a sterile bandage. 
The rectum and colon were flushed with warm saline solution. An injection of 5 
cubic centimeters of antitetanus serum was given with the usual antitoxin syringe. 
As no effect was evident from the injection, a second injection of 5 cubic centimeters 
was administered twelve hours later. Symptoms of improvement followed and the 
child recovered. 

A second case of tetanus was one caused by scratching an open wound situated 
near the nose, while playing with a canary bird. Symptoms of tetanus appeared 
two days after infection. This case was also seen in consultation by Dr. George F. 
Shrady. Large quantities of tetanus antitoxin w r ere injected with no beneficial 
result. The case ended fatally. In this case the infection was traced to some 
canary birds which were in the same room as that occupied by the family. 

Prognosis and Course. — The duration of fatal cases is seldom more 
than one or two days. Those tending to recovery usually extend from one 
to three weeks. 

While occasionally cures are reported, five out of ten seen by me have 
ended fatally. I have seen cases both in this country and abroad, injected 
with sufficient antitoxin, end in recovery. 

Treatment. — The bromides of potassium and sodium, chloral hydrate, 
belladonna, and opium are among the anti-spasmodics used. It is essen- 
tial to give large doses or no effect will be produced. Calabar bean has been 
lauded by some authors and can be given hypodermically. 

The literature records a great many cases where the antitoxin was in- 
jected directly into the brain. In the new-born baby this method should be 
used, as there is no obstacle to the introduction of the needle through the 
open fontanel. 

In one case treated by me the antitoxin was injected through the ante- 
rior fontanel. 

Epilepsy. 

Epilepsy is frequently seen in very young children. Some writers state 
that it develops in children approaching puberty. I have seen epileptic 
spasms in children under 1 year of age. 

Etiology. — Children whose parents are drunkards or where nervous 
diseases exist are predisposed to this condition. According to Berkely, 33 
per cent, of these cases give a history of alcoholism in one parent. Rachitic 
infants are frequently seen wdth epileptic seizures, so that it is quite pos- 
sible that they are predisposed. Children who have suffered with convul- 
sions in early life frequently have epilepsy later in life. This has led some 
authors to believe that convulsions and epilepsy are as cause and effect. 



802 DISEASES OF THE XERVOUS SYSTEM. 

Undoubtedly many cases of this kind exist. Statistics prove, how- 
ever, that one-half of all eclamptic children have no further nervous dis- 
eases in later life. Hence, we must not claim that if an infant suffers ivith 
eclampsia it must necessarily become an epileptic. 

An injury to the head, fright, or sunstroke may possibly cause this dis- 
ease. Some authors state that epileptic convulsions are intimately asso- 
ciated with adenoid vegetations, phimosis, and masturbation. Foreign 
bodies in the nose, throat, and ear may occasionally be predisposing factors. 
Other writers believe that menstrual disorders will provoke epilepsy. 

"The etiology of idiopathic epilepsy is mainly to be sought in alco- 
holism in the parents, which induces a defective organization of the brain 
structures in the descendants. Inherited syphilis is a less frequent factor. 
The signs of inheritance are chiefly seen in the departure from the normal 
in the skull formation, microcephalus, macrocephalus, as well as asym- 
metries of the skull and facial bones. Flatness of the cranial arch is found 
in a considerable proportion of epileptics, particularly among the males. 
Signs of rickets are especially frequent in epileptic children. Aronsohn, 
in a study of heredity among 508 epileptics, found a history of neuro- 
pathic disease in the parents in 32 per cent. Females showed a stronger 
tendency to inherit the disease than males, 33 per cent, against 30 per cent. 
The disposition on the part of the mother to transmit epilepsy is greater 
than that of the father (39 1 / 2 against 29 per cent, of inherited cases). 
Where both parents were hereditarily burdened, 63 per cent, of the children 
inherited the disease. In 82 per cent, of the inherited cases, the disease 
began before the twentieth year of life. Wildermuth, in 145 cases of early 
epilepsy, found inherited tendencies in 49 per cent., drunkenness on the 
part of the parents contributing nearly one-half (21 per cent.) of the 
examples. Traumatism in early life furnishes a small number of cases 
of epilepsy. Among 210 patients assembled by Wildermuth antecedent 
injury to the head had occurred eight times. In the majority of the trau- 
matic cases, the seizures followed the injury within a few days or weeks, 
seldom after months. Epileptiform seizures and their sequels are some- 
times found where there has been antecedent meningitis, porencephalia, or 
cerebral haemorrhage in infancy; they may also result from acute infec- 
tious processes, but in these instances they are to be regarded not as be- 
longing to true epilepsy, but as the symptomatic expression of a coarse, 
irritative cerebral lesion" (Berkley). 

Pathology. — Gowers states that the disease is probably located in the 
gray matter of the cortex. It should be regarded as a muscular spasm^ the 
result of the sudden overaction or discharge of the nerve cells. 1 



Gowers. Diseases of the Nervous System, Amer. Ed., 1888. 



EPILEPSY. 803 

Of 1450 cases of epilepsy studied by this same writer, 12 per cent. 

began during the first three years of Life, and 46 per cent, between the 
tenth and twentieth years. 

An interesting point was brought out by Herter and Smith/ who 
studied 238 specimens of urine taken from 31 epileptics. 

They noticed that in 72 of these observations there was excessive in- 
testinal putrefaction, as shown by the presence of ethereal sulphates in the 
urine just before the occurrence of the spasm. These authors were war- 
ranted, therefore, in their conclusion, that there is a distinct association 
between the intestinal poisoning and the epileptic seizures. We can readily 
see that the treatment of any case of epilepsy must be followed along the 
lines just described. 

Symptoms. — There are two kinds of attacks usually met with : first, 
the grand mal; second, the petit mal. 

Grand Mal Form. — The attack may come on gradually or it may be 
sudden. Children old enough to complain frequently have a warning of 
the attack known as the aura. This aura consists in a series of symptoms, 
such as a twitch in the leg or the face, constituting a local spasm described 
by some authors as a "motor aura." Then again there may be abnormal 
sensations, such as a tingling or numbness in any part of the body, until 
the patient suddenly falls with the spasm. There may be an unusual 
tremor or a shivering sensation, and the patient may fall to the floor with 
a sharp cry, having the jaw set and all the muscles of the body in tonic 
spasm. The eyeballs are usually rolled upward. After a few seconds, dur- 
ing which the skin is cyanotic, a second stage follows in which there are 
clonic spasms. There may be involuntary spasms of the bladder and bowel. 
In the clonic stage the muscles frequently contract and relax violently. 
Not infrequently the tongue is apt to be caught between the teeth and is 
bitten. There may be frothing at the mouth. Very marked rigidity of 
the sterno-cleido-mastoid. The head may be thrown backward or it may 
be twisted to one side. The extremities may relax and then become rigid 
again, and the cyanosis gradually disappears. Children usually fall into 
a deep sleep as though exhausted after the end of the clonic stage. This 
sleep lasts hours at times. Children old enough to describe symptoms will 
state that they have no knowledge of what has happened. They awake just 
as children do after a deep chloroform narcosis. 

Petit Mal Form. — This is a milder type of the condition above de- 
scribed. The attacks, instead of lasting minutes and hours, usually last 
but a few seconds. The child does not fall, but may sit quietly during the 
seizure until it passes off. 

An aura is absent in this condition. The attacks not infrequently 



New York Medical Journal, August and September, 1892. 



804 DISEASES OF THE NERVOUS SYSTEM. 

happen several times a day. They may also occur at night. In some 
children we have both varieties. 

Differential Diagnosis. — Epilepsy is frequently confounded with hys- 
teria. In hysteria there is partial consciousness. In epilepsy there is a 
loss of consciousness. The biting of the tongue and symptoms, such as the 
nocturnal appearance of the attacks, will aid in establishing the diagnosis. 
There is usually a dilatation of the pupils. 

An epileptic may have an attack in inopportune places, such as the 
street or on a hot stove, whereas a case of hysteria usually selects a place 
indoors, entirely out of danger. 

Prognosis and Course. — This disease does not follow a regular course. 
The usual interval between seizures in the very beginning may be months. 
Eegular intervals of epileptic attacks may be every two or four weeks. In 
some severe cases seen by me the attacks came on every day. It is not 
unusual for epileptic seizures to come at night only. "When such is the 
case the diagnosis is very difficult. 

The outcome depends on the condition of the patient. A child may be 
seized with an attack while on the street and be killed by an accident. In- 
stances are on record where epileptics have fallen in the water and were 
asphyxiated during the spasm. Traumatic epilepsy will occasionally be 
cured by surgery. Generally speaking, the cases of epilepsy seen by me did 
not do well with surgical treatment. 

Treatment. — A case of this kind should never be left alone, owing to 
the danger of accident during the epileptic seizure. If a cause exists, such 
as adenoid vegetations or phimosis, the same should be radically treated. I 
have previously mentioned the results of Herter's examinations of the urine; 
thus we find that the products of indigestion are usually found in epilepsy. 

Dietetic Treatment. — Arguing from this point of view, the stomach 
and bowels must not only be constantly supervised, but the lightest kind of 
nutrition that will yield strength should be ordered. The action of the 
bowels must be frequent. The slightest constipation should not be per- 
mitted. 

Cereals, vegetables, and fruits, in fact, the lightest kind of dairy 
products, should be ordered. Meat and similar stimulating nutrition should 
be enjoined. Water and liquids should be freely given. Xeither alcohol, 
tea. nor coffee should be allowed. 

Hygienic Treatment. — Children so afflicted should be kept out of doors 
as much as possible. They should not attend school. They should have 
cheerful surroundings and avoid all useless excitement. They should be 
given a bath daily and a proper amount of sleep. 

Drug Treatment. — Sodium bromide seems to be the drug par exc&S 
lence in the treatment of this disease. Children can take as large if not 
iarger doses of bromide than adults, I have frequently given 10 grains o> 



Ail 11 : MYELITIS. 805 

bromide of soda to a child 1 year old, and repeated the same several times 
a day. 

We must study the tolerance of every child by carefully increasing 
the dose until the physiological effect of the same is produced. Seguin 
advises giving large - - arly in the morning, small doses during the day. 
and large doses at night. The reason for the large dose at night is the fre- 
quency with which the attacks appear in the night. Belladonna is advised 
- nie authors. Chloral hydrate is frequently useful when combined 
with the bromides. I sometimes use arsenic alone when the bromides cause 
acne. 

Restorative treatment should be combined with this anti-spasmodic 
treatment. The system should be strengthened by giving iron and strych- 
nine. The use of malt extracts and codliver-oil will be found beneficial. 
Tiegarding the surgical treatment of epilepsy Sachs, quoted by Holt, -ays : — 

"In a case due to a traumatic or organic lesion an early operation may 
prevent the development of cerebral sclerosis. If an early operation is not 
done, the occurrence of epilepsy is a warning that secondary sclerosis has 
been established and an operation may prevent it from increasing. Opera- 
tion must include the removal of the diseased area ; here, if all other parts 
are normal, a cure may result. Under favorable conditions a few cases of 
epilepsy may be cured by surgery and many more improved.'' 5 

B. Sachs and A. Gerster 1 give the following summary: An opera- 
tion is permissible in traumatic epilepsy when the case is not over 1 or 
2 years old. When there is a depression of bone, the operation is indi- 
cated at a later period, but should not be delayed. Trephining alone is 
sometimes sufficient. If the disease is of short duration, a part of the 
cortex may be incised. The complication of infantile cerebral paralysis. 
if the case be recent, is no contraindication to the operation. It must not 
be performed in epilepsy of long duration. 

Acute ^Myelitis. 

This condition consists in a diffuse inflammation resulting in destruc- 
tion of spinal elements and the softening ot the cord. 

Etiology. — It is not a rare condition, but is most frequently seen as a 
complication of the infectious diseases. Chilling of the surface of the body 
seems to favor the development of this condition. Some authors state that 
it follows metallic or other chemical poisonings. It is frequently associated 
with spinal trouble, such as Pott's disease. Injury is frequently given as 
a cause, but syphilis is the most frequent c iu& 

Pathology. — MacroscopicaJ: The cord is seen thickened and sur- 
rounded by hyperaeniic meninges. The substance of the cord is much 
softer than normal and sometimes resembles pus. Frequently small punc- 

1 American Journal Medical Science. October. 1S9(J. 



806 DISEASES OF THE NERVOUS SYSTEM. 

tate haemorrhages and even larger extravasations of blood can be seen 
microscopically. In severe disintegration of the cord, the microscopical 
findings are useless. It is in the mildest forms that pathological changes 
can best be studied. In the dilated blood-vessels we find leucocytes and 
granules of myelin. Corpora amylacea are frequently seen. 

Symptoms and Diagnosis. — The symptoms depend on the portion of 
the cord tissue involved, and on the severity of the process. In syphilis we 
have a slowly developing condition weeks and months before myelitis 
symptoms pointing to this condition can be noticed. If children can 
complain they describe a sense of weight in the legs which gradually 
increases so that in a few days the limbs are entirely palsied. Convulsions 
and delirium have frequently been noted. ^Yhen the reflexes are anatom- 
ically related to the affected segments they disappear, and below that level 
they are increased; after a few days, if the cord has been entirely de- 
stroyed at the inflammatory focus, the reflexes are entirely abolished 
(Church). "Provided the posterior roots and meninges are involved, pain 
in the back and limbs is a prominent symptom, but rarely is of an ex- 
cruciating character at the onset. At the upper level of the inflammation 
some pain is the rule, which gives rise to a band or girdle sensation and a 
zone of Iryperaesthesia about the abdomen or chest. This sign, with the 
paralysis, definitely localizes the upper limit of the lesion, but if it be in 
the lower cervical region this sensation passes down the arms and is not so 
sbarply defined. Lesions in the cervical region are also marked by impli- 
cation of the cilio-spinal center, with consequent dilatation of the pupil. 
Continuous priapism is then, too, a usual occurrence, and the intercostal 
muscles and heart may be affected. Below the lesion, and depending upon 
its intensity, there are variations in sensibility to all forms of stimulation, 
from slight blunting to the usual complete anaesthesia. Sensations of 
drowsiness and aching in the paralyzed and anaesthetic limbs are some- 
times mentioned; and cramps and drawing up of the limbs frequently 
occur early, and later are the rule. Distinct muscular atrophy related to 
the portion of the cord affected takes place, but in the trunk it is not 
readily discernible. The paralyzed limbs during the first few days are 
abnormally warm, but soon present a subnormal temperature; sluggish 
circulation and emaciation ensue, with oedema of the feet and legs if the 
limbs are left any length of time in a pendent position. If the lesion is low 
down, the atrophy is a marked feature and the reaction of degeneration is 
present. Under the influence of pressure, bed-sores form on prominent por- 
tions of the body and limbs, and this very early. In some cases within the 
first week immense sphacelation may take place over the sacrum, which 
cannot be explained by pressure and the moisture from the urine, but im- 
plies a dystrophic condition of cord origin. Trophic symptoms (bed-sores) 
•are especially liable to occur when the lumbar cord is the seat of the disease. 



MALFORMATION OF THE SPINAL CORD. 807 

Prognosis and Course. — The course of the disease is chronic. The 
condition varies but little. The Symptoms get worse and worse until death 
ends the trouble. From a few weeks to a few months may terminate the 
disease. 

At times if it is associated with or dependent on Pott's disease, im- 
provement may he expected. Sometimes myelitis is caused by syphilis 
either in its active form or due to a syphilitic neoplasm. It is rare in such 
conditions to effect a cure. 

Treatment. — If specific conditions such as syphilis exist, then anti- 
luetic treatment is required. Iodide of sodium can be given in very large 
doses, 5 to 50 grains per day. The general indications, such as attention to 
the stomach and bowels, must be met and stimulated if required. It is im- 
portant to feed a patient in this condition with very nutritious food. Coun- 
ter-irritation over the spine is advisable. For this purpose tincture of iodine 
or mustard will be useful. I insist on absolute rest in bed (water bed if 
possible) and in frequent change of position. 

Chroxic Myelitis. 

This condition is usually the continuation or the prolongation of acute 
softening of the cord. It is here that we find bed-sores as well as disturb- 
ances of the bladder and bowels. 

Treatment. — The treatment consists in what has been previously ad- 
vised in the acute condition. Life can only be prolonged by giving tone to 
the system with proper food. 

llALFORAtATIOX OF THE $PIXAL CORD ( SPINA BIFIDA) . 

The most frequent malformation seen is spina bifida. It affects the 
vertebral canal and ends in a protrusion of a small or large soft tumor filled 
with serum. This serum is a clear yellowish liquid similar to cerebro-spinal 
fluid. We are indebted to Humphrey 1 for an accurate description of this" 
lesion. He says : "Spina bifida is due to an early failure in development, 
in most cases before the cord is segmented from the epiblastic layer from 
which it is developed. Hence, it remains adherent to the epiblastic cov- 
ering, and the structures which should be formed between the cord and the 
skin are developed. For this reason we have in the wall of the sac a fusion 
of the elements of the cord, nerves, meninges, vertebral arches, muscles, and 
integument. If the error in development occurs later, the cord and nerves 
may be attached to the sac, but not intimately fused with it; in still other 
cases the cord does not enter the sac at all. The malformations may occur 
before the central canal is closed, or, if closed, it may reopen from the 
accumulation of fluid. It is probable that the accumulation of fluid first 



1 Lancet, March 28, 1885. 



g08 DISEASES OF THE NERVOUS SYSTEM. 

occurs, and that this prevents the union of the parts of the vertebral 
arches. 

'"Although the tumor is generally associated with a bifid spine, this is 
not necessarily the case. The protrusion may take place through the inter- 
vertebral notch or foramen, or there may be a fissure of the bodies of the 
vertebra?, and an anterior tumor projecting into the cavity of the thorax, 
abdomen, or pelvis, spina bifida occulta. The principal anatomical varieties 
are meningocele, meningo-niyelocele, and syringo-niyelocele." 




Fig. 25$. — Case of Spina Bifida. Spontaneous cure. Male child, 6 
rears old. Now suffers with paralysis of both legs. Well nourished. Xo 
evidence of hydrocephalus. (Original.) 

The following ca.se of spina bifida occurred in my private practice. A boy, 6 
years old., was brought to me with a history of having a very large growth in the 
lumbar region. The sac burst spontaneously. Since that time the boy has a double 
paralysis, and also suffers with incontinence of urine and faeces. He was brought to 
me for the treatment of the paralysis. The general condition was good and he 
appeared well nourished. There was no evidence of hydrocephalus. 

Treatment.— The treatment of spina bifida is surgical. I have seen 
a number of successful pa« - 

Hereditary Ataxy (Friedreich's Disease). 1 

This condition is caused by a degeneration of the posterior columns 
of the spinal cord. As a rule several members of the same family are 

affected. 



1 1 am indebted to Williams's excellent monograph for some points in this 
article. 



IMAM ILK BPLNAL PARALYSES. 809 

Etiology. — This usually Been at or about the period of 

puber -. scarlet fever, or any other acute infections may 

precede the development of this condition. 

Pathology. — T. 3 seen are: W S lei w in the posterior columns 

(columns of Goll in their whole extent, and columns of Burdach in their 
upper part), in the direct cerebellar tract extending laterally into the column 
vers, in the lateral columns (crossed pyramidal tract), in the gray 
matter (columns of Clarke, and posterior horns j. In some cases dilatation 
of the central canal has been observ- . 

Symptoms and Diagnosis. — The motor system shows the most charac- 
teristic symptoms. The patient stands with the feet far apart. The body 

s and there is an unsteadiness while trying to maintain the equilibrium. 
The gait resembles that of an alcoholic intoxication. A tremor of the 
hands and head and choreiform movements affect the same parts. Pa: 
and emaciation may be present. The tendon reflexes are absent as a rule, 
but their presence does not speak against the diagnosis in the early stage of 
the disease. The eyes -how nystagmus. There is no optic atrophy. There 
is vertigo. The speech is slow. The intellect seems impaired. There is a 
peculiar clubbing of the feet. The foot is short. The toes are over- 
extended, the instep high and hollow. The Babinski phenomena or hyper- 
extension of the big toe may be the first symptom of this condition. 

The prognosis is grave. The disease lasts years. 

Treatment. — The disease runs its course, although electricity and 

rative treatment plus massage may be tried. The disease usually ends 
fatally. 

IXFAMILE SpiXAL P ANALYSIS (POLIOMYELITIS). 

This disease is characterized by m onset of fever, then paralysis, 

usually followed by muscular atrophy and imperfect bone development, 
sometimes by deformity. 

Etiology. — The majority of cases occur before the tenth year. Some 
authors state that three-fifths are seen before the fourth year. The most 
susceptible period s - be during the last six months of the first year. 
The majority of cases occur in summer (Sachs). 

Most cases occurring in hot weather begin with fever, diarrhoea, and 
vomiting. There seems to be reason to believe that the bacterial infe 
in the intestine generates a toxaemia which may be an etiological factor. 

Pathology. — We are indebted to Provost and Goldscheider for a com- 
plete study of the pathology of this condition. The latter believes that "a 
condition of irritation is present in the walls of the blood-vessels of the 
cord leading to their dilatation and to the proliferation of their endothelial 
elements. Later degenerative changes occur in the ganglion cells, as well 
as in the new fibers appearing in the vicinity of the altered blood-vessels." 



810 



DISEASES OF THE NERVOUS SYSTEM. 



The clinical data show this to be due to an invasion of bacteria, although 
it has not yet been proven. The fact that the disease appears in epidemics 
points to the possibility of bacterial invasion. The inflammatory process - 
limited to the anterior horns or extends to the medulla and pons. The 
inflammatory process is interstitial, not parenchymatous. "The muscles 
become atrophied. The fibers diminish in size, possibly disappearing, their 
place- being filled by adipose tissue.'* 




Fig. 250. — Poliomyelitis. Sclerosis and cicatricial atrophy of the left 
anterior horn of the fourth cervical nerve after acute anterior poliomyelitis. 
a Normal anterior horn with ganglion cells, (b) atrophic anterior horn. 
i Ziegler. | 



Table No 

ACUTE SPIRAL PALSY. 

Onset sudden, with fever, coma, and 
convulsions. Convulsions rarely re- 
peated after first few days. 

Paralysis flaccid, associated with 
atrophy. Marked trophic changes. De- 
formity without contractures. 

Paralysis widely distributed,, possibly 
involving all extremities, or narrowly 
limited to one member or even a single 
group of muscles. 

Electric reactions altered (R. D.). 

Deej reflexes diminished or lost. 

Intellect never permanently involved: 
no epilepsy. 



102. 

ACUTE CEP.EBP.AL PALSY. 

Onset sudden, with fever, coma, and 
convulsions. Convulsions apt to be re- 
peated. 

Paralysis spastic, no atrophy, no 
marked trophic changes. Associated 
with rigidity and contractures. 

Paralysis generally hsemiplegic, some- 
times diplegic or paraplegic. Mono- 
plegia rare. 

Electric reaction normal. 
Deep reflexes exaggerated. 

Intellect often involved: epilepsy fre- 



quent | Sachs). 

Symptoms. — Acute poliomyelitis usually appears as any other infec- 
tious disease. Children usuallv have fever reaching 102° or 103" F.. fol- 



INFANTILE SPINAL PARALYSIS. 



811 



lowed by a sudden paralysis; sometimes vomiting and convulsions may 
also be present. The reflexes arc greatly diminished or entirely absent. 
The emaciation occurs very early and the part affected is limp. The mus- 
cles lose their tone and are soft and flabby. The surface temperature is 
cold. Shortening takes place. The electric reaction of the paralyzed mus- 
cles and nerves shows "the reaction of degeneration," the anodal closure 
contraction being equal to or greater than the cathodal closure contraction. 



! 

/ 

/ / 

mm!—*} 


1 1 




>WB 




Fig. 260.— Infantile Paralysis, with Atrophy 
and impaired Growth of the Right Leg, and 
Drop-foot ; Four Years After the Onset. Note 
atrophy on affected side. (Case of Dr. M. Allan 



Fig. 261.— Infantile Paralysis, with Atrophy 
of the Right Leg. The curvature of the spine 
is secondary to the shortening of the leg. (Case 
of Dr. M. Allan Starr.) 



Starr.) 

According to Sachs the reaction to the faradic current is lost at once, but 
to galvanism it remains or is increased for some time and then is lost, 
except that it may appear to very strong currents. There may be tender- 
ness along the affected nerve and pain in the muscles during the acute 
stage. The bladder and rectum are usually not involved. The brain is 
not affected, so that this condition per se does not give rise to mental de- 
rangement. 



812 DISEASES OF THE NERVOUS SYSTEM. 

Diagnosis. — This disease usually follows fever. At times it is a one 
day's fever followed by paralysis. There is "a stationary stage, lasting one 
: -:x weeks. Then a period of improvement," lasting about six to twelve 
months, and. lastly. *"a stage of permanent disability." 

The initial fever is sometimes followed by pain in the limbs and the 
condition mistaken for rheumatism. In no other disease is the response to 
the fa radio current absent as early as in this condition. In diphtheritic 
palsy the previous history will assist in clearing up the doubtful diagn - - 
Atrophy of the muscles occurs very early and is an important diagn<> 
guide. 

Prognosis. — It is difficult to state what will be the outcome of a case 
of this kind. I have seen some severe cases entirely recover. The severity of 
the beginning of an attack is no guide as to its outcome. Some mild ca - - 
may leave permanent deformities : as a rule, however, some muscles remain 
permanently paralyzed. The reaction of the muscles with the faradic 
current should be the guide in estimating the outcome of any c 

The following case will illustrate this condition as seen by me at the 
children's department of a large outdoor service : — 

Baby Romeo, eleven months old. male infant, was referred to me by Dr. E. D. 
Lederman. The child had measles when six months old. This was followed by 
bronchitis. Was breast-fed three months and since then has received equal parts of 
cows' milk and water. Dentition has been normal. He has six teeth. Has had 
an occasional dyspeptic attack. The mother states, that about four months ago 
the child had fever lasting one day: on the following morning the legs were 
paralyzed. This paralysis gradually improved and today is confined to the right 
side only. There is a distinct anaesthesia over the foot, which is gradually less 
toward the thigh. The patellar reflex is absent on the right side. There is no 
ankle clonus. The plantar reflex is very slightly present. The foot is very cold; 
there is marked atrophy of the limb noticeable. A haemic murmur is heard with the 
first heart sound, and the same is also heard in the vessels of the neck. The 
diagnosis of poliomyelitis was made. Massage and galvanic electricity were ordered, 
strychnine, Vioo grain.- a l=o baths consisting of 250 grams ferri sulphas, crude, every 
third night followed by brisk friction. An antiscorbutic diet was also prescribed. 

Treatment. — Considerable progress has been made in the treatment of 
infantile paralysis. The former method of placing the paralyzed limb into 
plaster of Paris or braces is gradually being abandoned. In older children 
"muscle education" is commended and the child guided through active 
exercises, so that atrophy from non-use is prevented. 

A comparison of this latter method of muscle active treatment, rather 
than the muscle passive treatment, which latter results from splints, bra 
a::d plaster casts, shows a decided leaning toward the muscle active treat- 
ment. Patience and persistence will be rewarded bv success after weeks 
and months of this treatment. The child's brain must be in sympathy 
with its movements : hence, the passive exercises, such as gymnastics or 



IM AN 1 II. i: SPINAL PARALYSIS. 






ssage, are far inferior to a method in which the child ran be instructed 

in the performance of various exercises in which the body and mind 

co-ordinate. It has been found by clinical experience, and such cases have 

reported by Teschner and others, that a muscle, be it ever s<> atrophied. 

ran l»e redeveloped by a system of carefully planned exercise?. 

Intramuscular injections of strychnine in doses of V 100 grain every 
other day gradually increa-ed until a -., grain can be given to a child 5 years 





Front \ iew. Side View. 

Fig. 202. — Infantile Paralysis. Xote drop-foot and drop-wrist. - 

old, younger children in proportion. Arsenic in the form of Fowlers 
solution may be given, in doses : 1 to 5 drops three times a clay. Electricity 
or galvanic current may be used in conjunction with massage, but gentle 
ssage will accomplish just as much, and more than violent rubbing by 
inexperienced hands. 

Restorative treatment should consist in giving concentrated food, such 
as milk, yolk of egg, broth, and gruel. Seabaths will aid in restoring normal 
conditions. The treatment must, be persisted in for months. 

In cases of drop-foot or drop-wrist, tenotomy may be required, but 
this should be left to the judgment of a conservative orthopaedist. 



: I am indebted to Dr. Dexter Ashler for the above illustrations. 






814 DISEASES OF THE NERVOUS SYSTEM. 

The bacteriological studies of Simon Flexner regarding the etiology 
of the disease have altered our conception of its cause. The treatment must 
therefore be directed toward elimination of toxin as much as possible. 
Urotropin (which liberates formaline) may be given in 2- to 3- grain 
doses several times a day. Hot packs over the affected parts have a stimulat- 
ing tendency. A warm sulphur bath using the crude sulphuret of potassium 
4 ounces for one body bath at a temperature of 102° F., repeated daily for a 
few minutes, acted beneficially in several of my cases. Lumbar puncture 
is useful in those cases of poliomyelitis complicated by polioencephalitis. By 
tapping the spinal canal 10 to 15 cubic centimeters of fluid will relieve 
intracranial pressure and frequently modify symptoms. Thus far intra- 
spinal medication has proven useless. Dry cupping of the spine may be 
tried every other day. 

Hydrocephalus. 

This is an accumulation of serum in the head: 

External Hydrocephalus. — When the effusion is between the dura 
mater and the pia. 

Internal Hydrocephalus. — When the lesion is in the ventricles of the 
brain. The latter condition is most common^ seen. 

Acute Hydrocephalus. 

This condition usually follows basilar meningitis. In acute hydro- 
cephalus the effusion is not large. Some authors state that no more than 
three or four ounces of serum are present. 

Chroyic Ixterxal Hydrocephalus (^Yater ox the Brain). 

This condition must not be confounded with tubercular meningitis. 

Etiology. — The cause of primary or secondary internal hydrocephalus 
is very difficult to determine. In some instances syphilis has been given as 
the causative factor. An interesting paper has appeared by D'Astros, 1 
who describes 12 cases in which hydrocephalus was associated with syphi- 
litic lesions, so that the condition was congenital. By some, chronic hy- 
drocephalus is believed to be due to tuberculosis. 

Pathology. — "The changes in the brain result from the gradual accu- 
mulation of fluid in the ventricles. The septum lucidum is usually broken 
down, and all the avenues of communication between the ventricular cav- 
ities are greatly enlarged. The continuous distention results in a gradual 
thinning of the brain substance which forms the ventricular walls; often 
these are found only one-fourth of an inch in thickness, or even less than 
this, the cortex being a mere shell." 

1 Revue Mensuelle des Maladies de 1' Enfance, Chapter IX, pp. 481 and 543. 



CHRONIC INTERNAL HYDROCEPHALUS. 



815 



The brain appears anaemic, bo that the gray and white gnbstam 
seiuble each other. The- bones of the skull show th< a na very plainly. 
The sutu: - - parated in some car-.-. Where prematni - ation has 
taken place, the head instead of being very lar_ . - :y small. This is 
called a microcephalic condition. Sometimes spina bifida is ass with 

this condition. 

Symptoms. — The first symptoms that attract attention are, that the 
head is increasing in size : that it seems very heavy : that the child appears 
stupid; that it does not notice things, but stares continuously. The fore- 




Fig. 263. — Hydrocephalic calvarium tor skull-cap h widely gaping 
fontanels and sutures. One-half natural size. (Langerhans.) 



head is very high, the fontanel distended and bulging. On palpating, the 
soft fluctuating liquid can be felt. The sutures are very wide apart. The 
pupils are usually enlarged, sometimes contracted. Convulsions are fre- 
quently present. While the head enlarges the body eniae: 

Prognosis and Course. — This disease usually terminates fatally about 
the seventh year. In rare instances the condition may extend through life 
with impaired mental faculties due to the brain trouble. Oases that have 
been reported cured should be viewed with suspicion. 

Treatment. — Aspiration has been tried by many, with no apparent 
benefit. I have never seen a good result follow the aspiration of the 
liquid, because the fluid returns very rapidly, so that nothing is gained by 
the operation. 



816 



DISEASES OF THE NERVOUS SYSTEM. 




Fig. 264.— Case of Chronic Internal Hydrocephalus. Xote the position 
of the eves and the globular shape of the head. Aspiration of the ventricles 
every week gave 50 to 60 cubic centimeters of a perfectly clear fluid. 
(Original.) 




Fig. 265. — Front view of same case. Xote position of eyes and ears. 
This is a characteristic expression of hydrocephalus. (Original.) 



ENCEPHALOCELE. 



-17 



Blistering, counter-irritation, strapping, and lumbar puncture have 
been tried by me with no apparenl Buccess. Iodoform collodion has been 
recommended by some. 

h\ a case seen in consultation with Dr. L. Harris, of this city, convulsions were 
relieved by lumbar puncture. 

Mercurial inunctions and large doses of iodide have been tried. If 
syphilis is the cause, then some benefit may be expected from specific 
treatment. 




Fig. 266. — Encephalocele. Infant 1 day old. admitted to my hospital 
service, having a globular tumor in the occipital region of the head. The 
tumor measured S 7 2 centimeters from above downward, and 8'/ 4 centi- 
meters from side to side. The autopsy was performed by Dr. John Larkin. 
(Original.) 

Mexixgocele. 

When there is defective ossification in the bones of the skull and some 
part of the membranes of the brain protrudes, it is called a meningocele. 
Some writers believe it is caused by an intra-uterine hydrocephalus. These 
tumors generally contain eerebro-spinal fluid in the bag of membrane. 
When pressure is exerted over the swelling, the liquid will be emptied into 
the brain. Sometimes cerebral symptoms will result from this mani- 
festation. 

EXCEPHALOCELE (OEKEBP.AL HERXIA) . 

In this condition there is a protrusion of the brain substance in addi- 
tion to the membrane. This protrusion takes place through the frontal and 

52 



818 DISEASES OF THE NERVOUS SYSTEM. 

occipital bones. It is usually a congenital deformity. If the tumor con- 
tains a portion of a dilated ventricle and is filled with cerebro-spinal fluid, 
it is called a hydro-encephalocele or hydro-encephalo-meningocele. 

A case of this kind was seen by me some time ago in which the tumor protruded 
through the occipital bone. It was a congenital deformity. Distinct pulsation could 
be felt. The tumor increased in size when the child cried. Convulsions resulted from 
forcibly pushing the tumor into the cranial cavity. 

Treatment. — The injection of 1 drachm of Morton's fluid after aspira- 
tion of some of the liquid contents may be tried. Morton's fluid : — 

I£ Kali iodide 30 grains 

Iodine pure - 10 grains 

Glycerine 1 ounce 

M. Inject 1 drachm after each aspiration. 

If no improvement is noted after some time, surgical treatment should 
be tried. 

Cyclops. 

This is a very rare condition and consists of the child having but one 
orbit, which is situated in the middle of the forehead at the root of the 
nose. 

Porencephaly. 

This consists usually of a defective development, leaving a hole in the 
brain. It is a congenital disease and may be located in any portion of the 
brain. 



CHAPTER IV. 

TUBERCULAR MENINGITIS (BASILAR MENINGITIS). 

This is usually a secondary condition. It is not a primary disease of 
the meninges. In infants, tubercular meningitis usually follows bone tu- 
berculosis, tuberculosis of the lymph nodes or joints, and not infrequently 
a tubercular otitis may extend and involve the meninges. 

Etiology. — The association of adenoid vegetation and the probable 
entrance of the tubercle bacillus through the lymph channels of the neck 
is the most probable means of infection. 1 (See article on "Acute Tubercu- 
losis.") 

Bacteriology. — There is no question about the association of the 
tubercle bacillus with this infection. It can be found in the spinal fluid 
withdrawn by a lumbar puncture. Other pathogenic bacteria may also be 
found. In one case reported by me we found the diplococcus intracellular] s 
in addition to the tubercle bacillus. 

Pathology. — The chief pathological condition is a growth of miliary 
tubercles. Associated with these we frequently find tubercular nodules of 
variable size, and in almost every case they are the products of ordinary 
inflammation of the pia mater — lymph or pus — together with an accumu- 
lation of fluid in the lateral ventricles of the brain. Holt says : "Frequently 
there are tubercles in the pia mater of the upper portion of the cord. The 
miliary tubercles appear as small gray or white granules, situated along the 
vessels of the pia mater. When few in number they are usually located at 
the base, especially along the Sylvian fissures and in the interpeduncular 
space. When numerous, they are most abundant at the base, but are also 
seen scattered over the convexity in small groups. In about half of my 
autopsies they have been limited to the base, and in no case were they seen 
exclusively at the convexity. Tubercles are often found in the choroid coat 
of the eye. The amount of lymph and pus present is rarely great, and 
never equal to that seen in simple acute meningitis. It is often a matter 
of surprise at autopsies to find the lesions so few, after very marked symp- 
toms. The inflammatory products are most abundant at the base. In addi- 
tion to the patches of greenish -yellow lymph, there are adhesions between 
the lobes of the brain and thickening of the pia. In cases which have lasted 
for several weeks, the pia mater in places is often very much thickened, 



*This view is maintained by W. Freudenthal, of New York. 

(819) 



820 



DISEASES OF THE NERVOUS SYSTEM. 



owing to cell infiltration and the production of new connective tissue, and 
it is studded with miliary tubercles, sometimes with small yellow tuber- 
culous nodules; frequently there is arteritis, which is sometimes obliterat- 
ing. 

"In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The lateral ventricles are usually distended 
with clear serum, sometimes with serum containing floceuli of lymph or 




I c 

Fig. 267. — Tuberculous Spinal Meningitis. Longitudinal Section of 
Spinal Cord and Posterior Roots, (a) Spinal cord; (&) pia mater; (c) 
subarachnoidal space; {d) arachnoid; (e) posterior roots, cellular infiltra- 
tion and containing isolated swollen axis cylinders; (f) vessel with cellular 
infiltration and proliferated wall; {g) cellular exudate in subarachnoidal 
space; (/) swollen axis cylinder. X45. (Ziegler.) 

pus; the amount present varies from one to four ounces in each ventricle, 
being always greater in the subacute cases. The walls of the ventricles may 
be softened. The distention of the ventricles leads to flattening of the 
convolutions from pressure against the skull, to bulging of the fontanel, 
and sometimes to separation of the sutures, if they are not completely ossi- 
fied." 



Tl'BERtT LAR MENINGITIS. 821 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not so 
often in infants. These nodules may be connected with the meninges, or 
they may be situated within the brain substance, usually in the cerebellum. 

The larger ones are elassed as brain tumors. Inflammatory products are 
rarely found in the spinal canal. 

Course. — The course of tubercular meningitis is from three to ten 
days, although the symptoms may last from four to eight weeks, or even 
longer. 

Child B. W., 5 years old. Father a physician and healthy. Mother healthy. 
Had just returned from the country in apparent good health. Was sent to school 
and seemed bright mentally and physically. Was a well-nourished child. Had 
had no previous illness excepting a disordered stomach. The first symptom of her 
present illness was headache. Had a coated tongue, loss of appetite and a slight rise 
of temperature,, from 100° to 101° F. The temperature was very characteristic. (See 
chart.) The parents suspected a slight dyspeptic attack and gave her a laxative. 
Her diet was also corrected. In spite of cleansing the stomach and bowels, the 
headache persisted and reached such an acute stage that the child cried and moaned 
continuously, and did not sleep. When I first saw the case the symptoms of an 
acute gastric catarrh were so evident that nothing further was suspected. The 
headache persisted in spite of bromides. The child complained of ringing in the 
ears. Had twitchings of the arms and legs. The bowels assumed a normal color 
and consistency. An examination of the eyes with the ophthalmoscope was first 
made by Dr. H. Jarecky and later by Dr. Idenry S. Oppenheimer, who found vision 
good,, no choked disk — engorgement of veins only — slight reaction of pupils. No 
evidence of tubercular disease was found. In the beginning of this illness the 
symptoms of headache were very prominent. The child appeared quite rational and 
the diagnosis of supra-orbital neuralgia was made. Dr. George W. Jacoby, who saw 
the case at my request, early in the disease did not believe that we were dealing 
with meningitis. Later on, however, the symptoms were positive. Dr. Abraham 
Jacobi, who saw this case later in consultation, diagnosed meningitis. At his 
suggestion leeches were applied and they afforded quite some relief. The head- 
ache reappeared with renewed vigor and remained incessant throughout the 
period of illness. Owing to the continued pain it was decided to relieve the intra- 
cranial pressure by lumbar puncture. I aspirated 45 cubic centimeters of clear spinal 
fluid, which was sent to Dr. Billings, of the Xew York Health Department, for 
examination. He reported the presence of the tubercle bacillus and the diplococcus. 
Dr. B. Sachs confirmed the diagnosis of tubercular meningitis. 

Strabismus was also present. There was marked facial paralysis. Xausea and 
vomiting occurred. There were spasms and twitchings, also a hsemiplegic paralysis. 
There was also a unilateral flush on the cheek and other well-marked evidences of 
vasomotor disturbances. The child was either soporose, in a semi-stupor, or crying 
and screaming with pain in the head. A distinct red streak remained when the skin 
was stroked with the linger nail, the so-called tache eerebrale. The Babinski reflex 
was also present. There was spastic rigidity of the entire body. The eyes were 
half open. Respiration was labored, at times — f'heyne-Stokes respiration. The 
pulse was small and compressible ami varied between SO and 160. The child died of 
extreme exhaustion and inanition, after suffering about ten day-- of terrible agony. 



822 



DISEASES OF THE NERVOUS SYSTEM. 



Symptoms and Diagnosis. — Very irregular symptoms show themselves 
in this condition. The clinical picture varies in each and every case. I 
have never seen two cases that showed exactly the same symptoms. Symp- 
toms of malnutrition, such as emaciation and general weakness, are very 




Fig. 268. — Case of Tuberculous Meningitis, well marked, ending fatally, 

(Original.) 

evident. Vomiting, projectile in character without nausea, is a common 
symptom. The temperature is slightly raised in the "beginning, but after 
the first week it usually rises from 100° to 103° F., or even higher. The 
pulse which sometimes is accelerator! is more often slower than normal. 



TUBER* ULAB MENINGITIS. 823 

Sometimes it is compressible, and may vary between eighty and one hun- 
dred and sixty (80-160) heats per minute. The respirations are increased 

and irregular in character, labored and sighing, or frequently Cheyne- 
Stokes in character. 

Tache Cerebrate. — The tache eerebrale is frequently present. This is 
produced by drawing the finger-nail quickly over the skin of the abdomen, 
arm, or leg. when a sharp bright mark remains for several minutes. 

v >me symptoms come on very slowly. Intense headache is complained 
of and is usually supra-orbital in character. In the case referred to in this 
chapter the symptoms were masked for a number of days. The eyes usually 
show tubercles in the choroid. In the case reported here, although the eyes 
were examined by two competent oculists, no evidence of disease could be 
found. Strabismus a^ well as facial paralysis are frequently seen as evi- 
dence of paralysis. Twitchings are frequently noticed. 

The Babin^sl-i reflex is very often present. 

The child sleeps with its eyes half open. There is marked evidence 
of vasomotor disturbance, such as unilateral flushes, and spastic rigidity of 
the entire body is repeatedly seen. 

Lumbar puncture will usually show a clear cerebro-spinal fluid. In 
this fluid the tubercle bacilli can be located. In some cases other pathogenic 
bacteria : for example, the streptococcus can be found. 

The prognosis is bad. I do not know of a single case of distinct tuber- 
cular meningitis that finally recovered. 

Treatment. — Lumbar puncture should in all cases be performed. For 
details regarding technique of lumbar puncture see chapter on ''Epidemic 
Cerebro- Spinal Meningitis." Tapping the fourth or fifth ventricle will 
certainly relieve intra-cranial pressure. Xo more than 15 to 25 cubic cen- 
timeters should be withdrawn at one aspiration. I look upon this as a very 
valuable diagnostic as well as therapeutic measure. The head should be 
shaved, and an ice-bag or ice-coil applied continuously. Xext in impor- 
tance several leeches should be applied behind the ears, over the mastoid 
process of the temporal bone. Cerebral engorgement can also be relieved by 
applying leeches to the ala? nasi : this will drain the blood through the 
frontal sinus. Eectal medication should be remembered. 

Large doses (5 to 10 grains) of bromide of sodium and sodium iodide 
should be given until quiet is insured. The bowels should be cleansed by 
a thorough irrigation with glycerine and water. Iodoform collodion (10 
per cent.) can be applied to the scalp, thoroughly, once or twice. 

Inunctions with unguentum Crede or mercurial ointment, at the nape 
of the neck, rubbed into the lymphatics, for at least twenty minutes several 
times a day. will frequently do some good. 

Peptonized milk. whey, soups, broths, zoolak. and buttermilk are indi- 
cated. Fnder no conditions should solid food he administered. If the 



324 DISEASES OF THE NERVOUS SYSTEM. 

child is in a coma., rectal feeding must be resorted to. (For details see 
chapter on "Kectal Feeding") 

Cerebrospinal Meningitis (Acute Meningitis, Spotted Fever, or 
Malignant Purpuric Fever). 

Cerebro-spinal meningitis is an acute infectious disease characterized 
by a sudden onset of symptoms. 

Bacteriology and Etiology. — The presence of the diplococcus intra- 
cellularis of Weichselbaum is usually the causative agent of this disease. In 
a few cases, streptococci ; in others, pneumococci have been found. 

Weichselbaum states that he believes the meningococcus is frequently 
present and lies dormant in the crypts of the tonsils and pharynx. For 
this reason he believes that, when a lowered vitality exists due to subnormal 
conditions, then the meningococcus gains access through the lymph channels 
to the meninges and sets up an acute and sudden infection. In addition 
to the presence of the meningococcus in the tonsils, this pathogenic microbe 
is frequently found in the nose from whence it probably gains access through 
the frontal sinuses and reaches the brain. The meningococcus can be trans- 
mitted and an infection disseminated by direct contact with infected secre- 
tions containing the diplococcus intracellularis. "Weichselbaum does not 
believe that the sudden appearance of a case of cerebro-spinal meningitis, 
in an otherwise healthy locality, is extraordinary when the etiological con- 
ditions, such as the possibility of harboring this diplococcus in the nose and 
throat, are remembered. 

Pathology. — In the early stage of this disease we note hyperaemic 
conditions in the brain and spinal cord. When the disease has progressed, 
the arachnoid appears cloudy, especially along the course of the blood- 
vessels from which a purulent exudate oozes. This purulent exudate in- 
volves all the tissues of the convexity and frequently extends to the base in 
the meshes of the pia and between it and the cortex. The fluid in the 
ventricles is as a rule increased, and may contain small flocculi of fibrin. 
Haemorrhage is frequently noted in this region. The joints show evidences 
of septic inflammation. The spleen is frequently enlarged. Evidences of 
infection and sepsis are present in all parts of the intestinal organs of the 
body. Multiple abscesses may occur, and not infrequently parenchymatous 
degenerations involve the kidneys, liver, and spleen. 

Purpuric spots or mottling, so frequently seen on the outside of the 
body, may sometimes be seen more distinctly in the internal organs. 

Climatic Conditions. — The greatest number of cases occur during the 
winter months, while sporadic cases are seen in the spring, summer, and fall 
months. 



PLATE XXV 






1. Meningococcus or Diploeoceus Intracellularis. derived from a lumbar punc- 
ture of a typical case. « Courtesy of Prof. A. Weiehselbaum. of Vienna, i 

2. Meningococcus Intracellularis. from a typical case of Cerebro-spinal Men- 
ingitis. Pure culture. (Courtesy of Prof. A. Weiehselbaum. of Vienna. > 

3. MicToeoceus Catarrhalis. Pure culture. ((Courtesy of Prof. Ghon. of 

Vienna.) (OriginaL) 



CEREBRO-SPINAL MENINGITIS. 



825 



Table No. 103. — Deaths front Cerebrospinal Meningitis hi Children under 
lo years.— New York City— 1902-1907 . 



Year. 


Old New York City. 
156 


Greater New York City. 
221 
225 


1902 




1908 


158 




1904 


805 


1056 
2775 


1905 




1906 




1032 

828 




1907 





Symptoms. — During the epidemic there were three classes of cases 
encountered: first, a mild type; second, a severe type; and third, an 
abortive type. 

Mild Type. — In this class of cases there is a slight rise of temperature, 
generally malaise, and perhaps vomiting. 

Abortive Type. — This type is usually seen in strong children who are 
able to withstand a severe infection. By reason of their health they are 
infected in a lesser degree, as shown by their symptoms and the rapidity of 
their convalescence. The onset is usually sudden, and I have seen meningeal 
symptoms subside within ten days with no sequela\ This happened in a 
case of a child with undoubted cerebrospinal meningitis, in which the 
diagnosis was confirmed by the bacteriological examination of the spinal 
fluid. Ehinitis with catarrhal discharge from the nose is sometimes an 
early symptom in this disease. Ehinitis is frequently found in the abortive 
type of the disease. The danger of having the meningococcus in the nose 
consists in the ease with which this pathogenic bacterium can enter the 
frontal sinus and thus give rise to encephalitis. In the abortive type of this 
disease there frequently is a nasal discharge in which the meningococcus 
intracellularis can be found long after the rhinitis has disappeared. The 
ambulatory cases are the ones which disseminate this infection because they 
carry the pathogenic bacteria from house to house. 

Severe Type. — In the severe type there is a sudden onset of symptoms. 
In older children a distinct chill is usually the first symptom noted. The 
skin feels hot. The temperature rises anywhere between 102-105° F. (38. S 
and 40.6° ('.), in the rectum. The pulse varies: it may be slow or very 
rapid. The respiration is irregular in character, sometimes sighing, and 
labored, but most frequently Cheyne-Stokes in character. Later on there is 
vomiting, pain in the head, in the frontal or occipital regions, and pain at 
the back of the neck. There is moaning and frequently delirium. Vaso- 
motor disturbances, such ;is the flushing of one ear or one cheek, are 



I II 



826 DISEASES OF THE NERVOUS SYSTEM. 

occasionally seen. The taclie cerebrate is usually noted when stroking the 
breast with the finger nail, as a distinct hyperemia follows and remains for 
several minutes. The tendons are very sensitive to the slightest pressure. 
The patellar reflexes are usually absent. When the thigh is flexed on the 
abdomen and we try to extend the leg there is considerable latent contraction, 
the so-called Kernig sign. This symptom alone should not be depended 
upon. Hyperextension of the big toe produced by stroking the sole of the 
foot, the so-called Babinski reflex, is not always present. It is also fre- 
quently noted in perfectly healthy children. In a series of fifty children 
examined by me, the Babinski reflex was found in forty. 

Brudzinski's neck sign in tuberculous and other types of meningitis is 
present in 100 per cent, of those ill with either cerebrospinal meningitis, 
serous or pneumococcous meningitis. 

Technique to Elicit Neck Sign. — The head is forcibly flexed with the 
left hand while the child is lying fiat on its back; with the right hand, 
pressure is exerted on the chest to keep the child from being lifted. If the 
sign is positive, both legs will flex on the thighs and the thighs on the 
abdomen. 

The identical collateral sign consists in flexing the leg on the thigh 
and the thigh on the abdomen, when the opposite lower member will assume 
the same position. 

The normal cytology of the cerebrospinal fluid varies from to about 
7 lymphocytes per cubic millimeter. In any meningeal irritation, acute or 
chronic, the lymphocytes increase in number. They may be increased in- 
definitely up to thousands. 

In a number of cerebrospinal fluids from infants, examined by Kaplan, 
he found that in the tubercular forms the lymphocytes predominate. In 
the other acute meningitides of children the polynuclears and lymphocytes 
claim about equal or nearly equal relations. It is marvelous how readily 
the polynuclears diminish if the case shows the slightest tendency to 
improve, and, vice versa, they increase as the inflammatory process grows 
worse. Pari passu with the polynuclear increase the Fehling reaction 
disappears. This point is extremely important, as there are a number of 
cases of tubercular meningitis where the tubercle bacillus cannot be found 
even if the antiformin or the Jousset method is used. In these instances 
I consider the copper-reducing substance in the cerebrospinal fluid as highly 
suggestive of the tubercular nature of the meningitis. The non-reduction 
of the Fehling solution or the appearance of a violet color change instead, 
in Kaplan's opinion, is significant of the non-tubercular nature of the 
affection unless a mixed infection is at hand. In case a double infection is 
demonstrated microscopically, the invader that has the upper hand in the 
infection usually reflects upon the behavior of the cerebrospinal fluid with 
the Fehling solution. If it is the tubercle bacillus it will reduce; if it is 



PLATE XXVI 





Cerebrospinal Meningitis. Autopsy showed a yellowish-green, muco- 
purulent exudate, cheesy in character, covering the anterior two-thirds 
of the cerebrum. The fluid obtained by lumbar puncture as well as that 
by intraventricular aspiration showed a pure influenza bacillus. The 
autopsy was performed by Dr. John Larkin. The fluid examined by Dr. 
Soph i an and Dr. M. D. Kaplan. 



CEREBRO-SPINAL MENINGITIS. 827 

another organism it will not. The latter phenomenon is due to the fact that 
it produces a marked increase in the polynnclears, which in some way are 
responsible for the non-reduction. The importance of cerebro-spinal fluid 
examinations in paediatrics needs no emphasis. 

Either constipation or diarrhoea may he present. The bladder acts 
well, although enuresis may exist. In some cases there is a marked retention 
of urine. The joints are usually swollen, simulating rheumatism. There 
is also a distinct petechial eruption in some cases. Out of a series of twenty- 
two cases seen by me, six had distinct petechia. In six others the skin had a 
distinct eruption resembling scarlet fever. Owing to the spots present in 
this condition, the disease was frequently termed "spotted fever." The 
pupils are usually dilated; they are sometimes irregular. I have seen cases 
during the epidemic of 1905 in which one pupil showed marked dilatation, 
while the other pupil was contracted to almost a pinpoint. Strabismus is a 
frequent symptom. Occasionally we note nystagmus. Photophobia is a 
frequent symptom. In one of my cases the child cried whenever a lighted 
candle was brought near the eyes. Opisthotonos is usually present. The 
severe rigidity of the sternocleidomastoid muscle in addition to the marked 
rigidity of the arms and legs forms a very prominent symptom during the 
course of the disease. Owing to these severe contractures we usually note 
constant moaning, most likely induced by the pain caused by the said 
contractions. 

Diagnosis. — A possible diagnosis of this disease can be made by examin- 
ing the fluid drawn by lumbar puncture. As a rule the spinal fluid is turbid 
or opaque. We do not find the spinal fluid clear and transparent, as it is 
seen in tuberculous meningitis. The presence of the characteristic diplo- 
coccus intracellularis described by Weichselbaum is usually noted. In rare 
cases the streptococcus and the pneumococcus have been found, but these 
latter are the exception. The bacteriological diagnosis, according to Weich- 
selbaum, depends on the diplococcus being Gram negative, or decolorized by 
Gram. It is important to remember that the Micrococcus calarr kalis is fre- 
quently found in the nasal passage; hence, great care must be exercised to 
differentiate the same, both in its relation to Gram staining and also in its 
morphological characters. 

The following two cases will serve to illustrate the method of 
treatment : — 

Case I. — Emilio G-., four months old, was admitted to the Sydenham Hospital, 
January G, 1909. Family history negative. 

Personal History. — Normal delivery. Full term. Bottle-fed since birth. 

Present illness began two weeks ago with twitchings of the muscles. One 
week ago mother noticed retraction of the head. There had been no vomiting. The 
baby had moaned almost constantly. 

Physical Examination. — Head showed bald occiput. The anterior fontanel was 
open and slightly bulging. The pupils were equal and slightly contracted. There 



828 DISEASES OF THE NERVOUS SYSTEM. 

was marked retraction of the head, amounting to opisthotonos. The chest showed 
poor expansion. There was a systolic murmur heard at the apex of the heart. The 
lungs over left base, posteriorly, showed small areas of dullness, bronchial voice, 
and breathing. The abdomen was retracted. The liver and spleen were not 
palpable. There was marked rigidity of both arms and legs. The reflexes were 
exaggerated. Kernig's sign was not elicited. Lumbar puncture showed turbid fluid 
in which the Diplococcus intracellularis was found. 

The duration of the disease was thirty-six days. By means of ten lumbar 
punctures, I aspirated 146 cubic centimeters spinal fluid, and in nine intraspinal 
injections, I injected 245 cubic centimeters Flexner serum. The average injection 
was about 30 cubic centimeters. The child made a complete recovery without any 
sequelae. 

Case II. — Intraventricular Method of Scrum Injection. — Dora R., 1 two months 
old, was admitted to the Babies' Ward of the Sydenham Hospital, October 2, 1909 ; 
she was a well-nourished, breast-fed infant, having had no previous illness. There 
was a sudden onset with vomiting, loss of appetite, rigidity of head, neck, and extremi- 
ties, rolling of the eyeballs, insomnia, and convulsive movements. The anterior fon- 
tanel was open one-half inch in diameter, and slightly bulging. The posterior fon- 
tanel was almost closed. The pupils were equal, and reacted sluggishly to accom- 
modation and light. 

The thorax, ears, and throat were excluded as a possible source of disease. 

On the fifth day after admission, and on two succeeding days, lumbar puncture 
was performed resulting in dry tap. With the three successive dry taps, the symp- 
toms of rigidity, opisthotonus, fever, and twitching increased. 

On October 20th, I decided to tap the lateral ventricles by entering the ante- 
rior fontanel at the right angle.'- The aspiration needle, about 8 centimeters in 
length, was introduced downward and toward the median line, at an angle of about 
20 degrees, to a depth of about 4.5 centimeters, the needle entering the lateral 
ventricles near the median line. About 15 cubic centimeters of turbid purulent fluid 
were withdrawn, which was identified at the Rockefeller Institute as a meningo- 
coccus intracellularis. The ventricles were then irrigated with normal saline solu- 
tion, at body temperature. The excess fluid was allowed to drain out through the 
needle, and 25 cubic centimeters of Flexner anti-meningitis serum were slowly 
injected into the ventricles. During the injection of the serum the infant changed 
in color from a waxy pallor to a uniform red flush all over the body. One-half hour 
after the injection of the serum the infant still remained flushed, perspired profusely, 
and had some frothing at the mouth. Otherwise the general condition was good. 
The temperature was 98° F. ; respiration. 80, and pulse, 120. 

On October 21st, the ventricles were again irrigated with 40 cubic centimeters 
of normal saline solution, and 20 cubic centimeters of serum were injected. 

October 24th, the child's general condition was very poor. Opisthotonos was 
marked. The body rigidly bent in the form of a bow. The arms were rigidly 
extended and the palms everted outward. 

October 25th, and during the following week, daily injections of 30-50 cubic 
centimeters of serum were injected either into the ventricles or, on two days, into 
the spinal canal and lateral ventricles. The total amount of Flexner serum injected 
was 180 cubic centimeters; the total amount retained in the ventricles and spinal 
canal was about 100 cubic centimeters. The child made a complete recovery. 

1 This case was presented at the Section on Pediatrics, Xew York Academy 
of Medicine, March 10, 1910. 
-See Plate XXYTTI. 



PLATE XXVII 




Cerebrospinal Meningitis due to the Influenza Bacillus. A, A. Anterior 
cerebrum covered with a thick muco-purulent exudate. B, B. Normal 
cerebrum. C. Superior longitudinal sinus. D. Reflected integuments. 
E. Frontal sinus. This infection has been seen by me in an infant 4 months 
old. The infection probably enters through the lymph channels in the naso- 
pharynx, thus reaching the base of the brain. The bacillus may also have 
entered through the frontal sinus. In the spinal fluid as well as in the 
ventricular fluid a pure culture of the influenza bacillus was found. The 
infant died of convulsions. The autopsy performed by Dr. John Larkin 
showed the anterior two-thirds of the cerebrum was covered with a thick, 
muco-purulent, greenish exudate, cheesy in character. The convolutions 
of the cerebrum were obliterated and covered by a thick exudate, the 
surface of which was marked by many whitish nodules and a number of 
pits near the falx cerebri. At the frontal lobe of brain on right side 
a dark, necrotic area was seen. Illustration shows the calvarium removed, 
the dura mater incised longitudinally on either side of the superior lon- 
gitudinal sinuses and reflected laterally, exposing the entire cerebrum. 



( EREBRO-SPINAL MENINGITIS. 



829 



The symptoms are gradually subsiding, the rigidity is lessened, bul on being 

handled opisthotonus is very evident. 

November 29th. No derided change, l>ui infani improving slowly. The lateral 

ventricles Mere aspirated and 50 cubic centimeters of (dear fluid which did not eon- 
tain the meningococcus 

withdrawn. 

December 6th. In- 
fant was di -charged 
cured. Xo complication 

of eyes and ears existed. 

It is now two months 
since this infant was dis- 
charged, she has since de- 
veloped a tooth, sleeps 
well, nurses well, and is 
a happy healthy infant. 

Lumbar Puncture. 1 
— The subarachnoid 
space is frequently tap- 
ped for diagnostic and 
therapeutic purposes. 
Either space between 
the third and fourth. 
or the fourth and fifth, 
lumbar vertebra? may 
be chosen. The child 
is placed on either side 
with the spinal curve 
toward the operator, 
in this way spreading 
the vertebra? so that 
the greater angle formed by the vertebra? is toward the operator. An 
imaginary line drawn through the crest of the ilium to the spine is an easy 
means of locating the place to puncture. 

Kind of Xeedle Required. — In making a lumbar puncture we should 
use such a needle as would be required in making a puncture for empyema. 




Fig. 269. — Anatomical Illustration Showing the Place 
Best Adapted for Lumbar Puncture. The needle should 
be inserted in the lumbar space shown by the cross. 
(Original ) 



Fig. 270. — Lumbar Puncture Xeedle. 



The needle should be pushed a little upward and forward until it enters the 
spinal canal, then the stylet should be withdrawn. If the fluid does not 
escape through the needle, then withdraw it slightly and reintroduce the 
stylet to dislodge anv obstruction in the caliber of the needle. Make the 



l First described by Quincke. 



g30 . DISEASES OF THE NERVOUS SYSTEM. 

puncture as simple as possible rather than lacerate the tissue around the 
vertebral column and cause bleeding by lateral movements of the needle. 

Amount of Fluid to be Withdrawn. — For diagnostic purposes 15 to 20 
cubic centimeters should be withdrawn, if the fluid is watery and clear. If 
the spinal fluid is turbid then the more we can withdraw, the better. I have 
withdrawn as much as 50 to 60 cubic centimeters. If the diplococcus intra- 
cellularis is found in the spinal fluid, it is especially important to with- 
draw as much of the fluid as possible. 

The site of puncture should be closed with a strip of adhesive plaster. 




Fig. 27 1. — Lumbar Puncture Made Between Fourth and Fifth Lumbar 

Vertebrae. ( Original. ) 

Local AncBSthesia. — Ethyl chloride in the form of a spray is useful in 
very sensitive children. It is not necessary to have general anaesthesia 

during this procedure. General rules of asepsis must be strictly applied to 
the child's skin, the operator's hands, and to the needle used. 
Dry Tap in Lumbar Puncture. — We may have a dry tap: — 

1. If the caliber of the needle is small, and the spinal fluid very thick. 

2. If adhesions are present at the base of the brain, preventing the 
passage of fluid from the ventricles to the subarachnoid space. 

3. If a successful puncture has been made, a dry tap may follow, due 
to inflammatory adhesions caused by the previous introduction of the needle. 

4. The closing of the foramen of Magendie is the most frequent result 
of the inflammatory process, resulting in dry tap. 

5. A fibrin clot, or the presence of the cord in front of the needle may 
prevent the outflow of the cerebro-spinal fluid. 

To be sure that we are in the spinal canal, if a dry tap exists, leave 
the needle in situ and introduce a second needle two spaces lower. Sterile 
water if injected through the upper needle will flow out of the lower needle, 
proving that we are in the spinal canal. 



CEREBROSPINAL MENINGITIS. 831 

The spinal cord in infants terminates about the level of the lumbar 

vertebra 1 . The introduction of the needle is simples! between the third and 
fourth, or the fourth and fifth, lumbar vertebra 1 . In these interspaces there 
is no cord, hence no injury can follow. An imaginary line drawn through 
the crest of the ilium corresponds to the fourth intercostal space. 

Prognosis and Sequelae. — Heretofore the prognosis was always bad; 
since the introduction of the Flexner serum a decided improvement has been 
noted. Where formerly TO to 80 cases died and only 20 to 30 cases 
recovered, we now have the reverse, 70 to 80 recoveries and only 20 to 30 
deaths. The prognosis is better if the serum treatment is given early in 
the disease. 

The duration of this disease may be short or very long. Young infants 
have been attended by me more than two months until recovery took place. 
Some cases after serum treatment recover entirely, others have atrophy of the 
optic nerve resulting in blindness. Deafness is a frequent and permanent 
injury in some cases. 

Treatment. — Fever Treatment. — Antipyretic measures such as cold 
packs, ice bag on the head, and tub baths are indicated. The coal-tar 
products, owing to their depressing effect upon the heart, should be avoided. 
Cupping of the neck and spine sometimes relieves internal congestion. 
Lumbar puncture should be performed. 

Eliminative Treatment. — This consists in cleansing the gastrointes- 
tinal tract with the aid of citrate of magnesia or calomel. When high fever 
exists, flushing the rectum and colon with a cold soap-suds enema will be 
found useful. 

Medicinal Treatment. — To relieve the vomiting cracked ice should be 
given, in addition to 1 -grain doses of menthol. To relieve muscular spasm, 
twitching, and delirium, hyoscine hydrobromate, in doses of 1 / 600 to 1 / 300 
grain, should be given and repeated every few hours. Morphine hypo- 
dermicalty, in doses of 1 / 50 grain, gradually increased, is also valuable. 
Leeches applied at the nape of the neck or over the mastoid portion of the 
temporal bone or at the alae nasi, will sometimes relieve. Sodium bromide, 
in 5 to 30-grain.doses, may be given until the systemic effect is noted. 
Codeine, 1 / 10 grain gradually increased until % grain is given, will fre- 
quently soothe the nervous system. The soothing effect of a warm bath is 
generally recognized. The bath should be given at a temperature of 100° 
to 105° F. in a bath tub of water to which % to y 2 pound of sulphur has 
been added. A warm sulphur bath may be given twice a day. The dura- 
tion of each bath should be at least ten to thirty minutes. 

Meningitis Serum. 1 — The specific value of the anti-meningitis serum 
has been demonstrated many times. In some cases reported there has been 

i I am indebted to Dr. Simon Flexner of the Rockefeller Institute for the anti- 
meningitis serum used in these cases. 



339 DISEASES OF THE NERVOUS SYSTEM. 

a sudden crisis and an amelioration of all the symptoms. My experience 
has been especially good in young infants under one year. While formerly 
all infants of tender age died, we now have a number of cases reported, 
including my own, in which absolute recovery has taken place. 

Intraspinal Injections. — By lumbar puncture we aspirate as much of 
the spinal fluid as possible, in some cases 15 to 30 cubic centimeters was 
obtained. Through the same needle left in situ I inject from 30 to 60 cubic 
centimeters of Flexners serum. The serum should be warmed before 
injecting, and should be injected slowly. It is better to elevate the hips and 
lower the head when injecting the serum. Daily injections of 30 to 60 cubic 
centimeters are required if no improvement is noted. 

Intracranial Injections. 1 — The scalp should be shaved and prepared 
with the usual aseptic precautions. The aspirating needle must be rendered 
sterile by boiling. It is then pushed through the anterior fontanelle down- 
ward and inward into the ventricles of the brain, at least one inch or more. 
The needle is inserted about one-fourth inch to one side of the longitudinal 
sinus. 

At the Babies' Wards of the Sydenham Hospital we have aspirated 
many times, 50 cubic centimeters of purulent liquid containing the diplo- 
coccus intracellularis in almost a pure culture. By using this same needle 
or one having a larger caliber, we irrigated, using a pint of normal saline 
solution. After draining off as much as possible; 50 cubic centimeters of 
Elexner's serum were injected. This plan of treatment was successfully 
used in two of my cases. In both cases the lumbar puncture yielded a 
dry tap,. 

The purulent discharge gradually lessened and the meningococci grad- 
ually disappeared, after continued serum injections extending over a period 
of four weeks. It was possible to aspirate and draw off between 50 and 60 
cubic centimeters of a clear transparent hydrocephalic fluid containing no 
germs. 

A decided reaction followed each and every injection of serum. During 
the injection of serum, the child changed in color from a waxy pallor to a 
uniform red flush all over the body. One-half hour after the injection of 
the serum, the child still remained flushed and perspired profusely, and had 
some frothy mucus at the mouth. 

The pulse rate was increased, the volume improved, and the tension 
much higher. The leucocytes were invariably increased. The polynuclear 
leucocytes were also increased after each injection. As a rule the mono- 
nuclear leucocytes and the lymphocytes were reduced within six hours after 
the serum injection. 

1 1 am indebted to my house staff, Dr. Bobrow, Dr. Clurman, Dr. Littenberg 
and Dr. Freund for careful notes and records of a series of cerebro-spinal meningitis 
cases treated at the hospital. See clinical case, page 828. 



PLATE XXVIII 





^*mm^' 



'^m^^ 



S Z_ o c A W C? O ^/ /" 



ec 



Translucent Head of Child. The needle entering the outer angle of the 
anterior fontanelle, and penetrating the lateral ventricle, which is seen in shaded 
outline. The falx is dimly seen. The right line running from before back- 
wards is the septum lucidum dividing the two ventricles. (Original.) 



CHRONIC PACHYMENINGITIS; 833 

Feeding. — Unless the strength is supported by food our patient will 
die of exhaustion. Feeding by mouth with peptonized milk, broth, gruel, 
and eggs is indicated. If, however, there is vomiting and the stomach does 
not retain food, then rectal feeding should be resorted to at intervals of 
three or four hours. This method of feeding has already been described 
in the chapter on "Infant Feeding/' 

After Treatment. — If the case progresses favorably, careful attention 
must be given to restorative treatment. Codliver-oil. Fowler's solution, 
iodide of sodium, and the hypophosphites must not be forgotten. Electricity 
must not be forgotten combined with massage and sea-salt bathing. They 
are indicated during convalescence. Milk, cream, butter, eggs and cereals 
should form the bulk of restorative nutrition. A decided change of air from 
the city to the sea-shore or to the mountains will prove beneficial. 

Acute Pachymeningitis (Inflammation of the Dura Mater). 

This condition frequently follows middle-ear disease, although it may 
be the result of injury to the cranium. It is frequently associated with 
inflammation of the pia mater (leptomeningitis). It is very difficult to 
diagnose. It usually follows ear disease and the symptoms of meningitis are 
associated. The treatment is surgical. 

Chroxic Pachymeningitis. 

Chronic pachymeningitis can be divided into two forms — hemorrhagic 
and non-hemorrhagic. There may be punctate haemorrhages or there may 
be very large hemorrhagic areas. Some authors state that this condition 
is very rare. It affects the inner layer of the dura mater. It is frequently 
called pseudo-membranous and hemorrhagic, or hematoma of the dura 
mater. 

In cases where life is prolonged for years, there may be partial or even 
complete absorption of the clot, followed by the formation of cysts, con- 
siderable inflammatory thickening of the pia with deposits of blood pigment, 
and finally atrophy and sclerosis of the cortex. The source of the hemor- 
rhage may be the rupture of a single large vessel, but more frequently the 
blood comes from many small vessels. 

Symptoms and Diagnosis. — It is very difficult to give positive symptoms 
by which this condition can be recognized during life. Coma, convulsions, 
stupor, and vomiting are the main symptoms. Unilateral hemorrhage causes 
rigidity affecting one arm and leg, but if the hemorrhage is diffused all 
the extremities are affected. The pupils may be dilated or contracted; 
sometimes one pupil is dilated and the other is contracted. The respira- 
tion and pulse are slow and irregular. There is usually fever, the tem- 
perature being as high as 105° or as low as 100° F. 

53 



834 DISEASES OF THE NERVOUS SYSTEM. 

Opisthotonos may be absent. The patellar reflex is usually exag- 
gerated. Convulsions appear and death ends the scene. 

The differential diagnosis, according to Holt, is as follows: "Without 
large haemorrhages, pachymeningitis interna cannot be diagnosticated ; and 
it is impossible to differentiate the hemorrhagic cases from other varieties 
of meningeal haemorrhage. It is important to make a diagnosis between 
pachymeningitis with haemorrhage, and acute simple meningitis. In the 
former we have a sudden onset; stupor occurring early, usually on the 
first day, gradually diminishing in cases of recovery, or deepening into 
coma in fatal cases; localized or general paralysis, also occurring early; 
there is no fever in the beginning, and only moderate fever at the close. 
In acute meningitis we usually have a higher temperature, especially early 
in the disease; coma develops later, and rigidity of the extremities is less 
pronounced. In certain cases, however, where the haemorrhage occurs in 
the course of some other disease, a differential diagnosis may be impossible." 

The prognosis is usually fatal. If small haemorrhages take place, the 
paralysis may remain for years. 

Treatment. — The scalp should be shaved and an ice-bag applied. 
Leeches should be applied to the mastoid to relieve cerebral congestion. 
Large doses of bromide and ergot will sometimes do good. The emunc- 
tories must be carefully watched and aided if necessary. 

Cerebral Paralysis (Spastic Diplegia. Paraplegia. 
Hemiplegia). 

There are two forms of palsy usually seen. When the face, arm, or 
leg is palsied it is called monoplegia. When the two lower extremities are 
affected, paraplegia. When one side is affected, haemiplegia. When both 
sides are affected, diplegia. 

They occur in one of three periods : first, during intra-uterine life 
(prenatal) ; second, traumatism during labor; third, palsies after birth 
of the child. 

Etiology. — Injury to the mother frequently injures the cerebrum of 
the foetus. Toxic conditions, especially those associated with the infec- 
tious disease resulting in muscular degeneration, frequently cause palsy. 
Compression of the infantile brain and its circulation during a slow labor 
may produce thrombosis or meningeal haemorrhage. This condition is most 
liable to occur in a primipara. Whooping-cough has caused cerebral haem- 
orrhage and injury and compression to the cortex ending in paralysis. 

Syphilis may be a frequent cause of this condition. Epilepsy is found 
in over two-thirds of all cases as a sequela. 

Pathology. — Very interesting data are contributed by Peterson and 
Sachs, to whom I am indebted for the following classification: — 



CEREBRAL PARALYSIS. 
Table No. 104. 



835 



Groups. 



Pathological Changes. 



I. Paralyses of intra-uterine onset. 



II. Paralyses occurring during 
labor. 



III. Paralyses acquired after birth. 



Large Cerebral Defects (true porencephaly). 

Hemorrhages of Intra-uterine origin (soft- 
ening?). 

Agenesis Corticalis. 

Meningeal Hemorrhage (very s-eldom intra- 
cerebral). 
Resulting conditions : meningoencephalitis 
chronica ; sclerosis ; cysts ; atrophies (poren- 
cephalies ) . 

Meningeal Hemorrhage (very seldom intra- 
cerebral) ; Embolism ; Thrombosis (in 
marantic conditions and occasionally from 
syphilitic endarteritis). 
Results of these vascular lesions ; cysts ; soften- 
ing ; atrophy ; sclerosis (diffuse and lobar). 

Chronic Meningitis. 

Hydrocephalus (seldom the sole cause). 

Primary Encephalitis (Striimpell) (?). 



"A summary of the pathological lesions resulting from acute ap- 
oplexies consists of atrophies, sclerosis, and other changes due to haemor- 
rhage; also, embolism and thrombosis." 

"Fatty degeneration of the blood-vessels is the probable explanation 
of the escape of blood in a large number of cases." Heart lesions, pneu- 
monia, and other infectious diseases predispose to embolism. 

The secondary changes result in sclerosis or areas of softening. "The 
sclerosis is largely responsible for the imbecility and epilepsy; transverse 
fibers connecting intimately all parts of the hemispheres." 

Spencer studied 130 cases of still-born children. He found 53 cases 
due to haemorrhage from the pia and arachnoid. In 29 cases there was 
bilateral haemorrhage, 10 in the left side only; 10 in the right side; 7 
in the lateral ventricles; 6 at the base of the brain; 1 case of intra-cere- 
bral haemorrhage; 4 cases of thrombosis of the longitudinal sinus. 

The following case occurred in the practice of Dr. A. C. Cotton, of 
Chicago : — 

Edith N., age 10 years, oldest in family of four children. Others normal. 
Mother not in good health during gestation. Labor lasted twelve hours. No 
forceps. Child was always irritable, but had no convulsions until four months of 
age, when first tooth appeared. There were frequent recurrences of spasms, two to 
four daily. Has never walked, stood alone, nor been able to support her head. The 
circumference of the head was nineteen inches. 



836 



DISEASES OF THE NERVOUS SYSTEM. 



Present Condition. — The skin is cool, with a tendency to cyanosis. The body 
is emaciated; there is a flaring of the ribs, and the spleen shows a distinct scoliosis. 

The mouth is open so that the saliva constantly dribbles. The jaws are de- 
formed and the face presents a starched appearance. There are contractures and 
spasticity in both upper and lower extremities. The reflexes are exaggerated. In- 
telligence nil. 

Symptoms and Diagnosis. — The following symptoms are common to all 
forms of palsy : Eigidity of the muscles, contraction of tendons, and exagger- 




Fig. 272. —Infantile Cerebral Paralysis. (Kindness of Dr. A. C. Cotton.) 



ation of all the deep reflexes. Convulsions and coma commonly precede the 
diseased state. Most cases of diplegia and paraplegia are congenital, while 
most cases of hemiplegia are acquired after birth. 

Palsies usually follow a difficult labor. Strabismus and facial paralysis 
are frequently noticed. Aphasia may be present in children that had 
previously learned to talk. The reflexes on the affected side, knee and 
elbow, are usually exaggerated (Peterson, Taylor, and Wells). 

When athetosis is found, it is usually associated with imbecility and 
idiocy. 

In associated movements the exact imitation of the paralyzed hand 



CEREBRAL PARALYSIS. 837 

and fingers of voluntary movements made by the normal hand and fingers 
takes place. Choreiform movements, called by Weir Mitchell post-paralytic 
chorea, are frequently mistaken for chorea. Peterson 1 describes two con- 
genital hemiplegias — a hitherto unnoted morbid movement to which he has 
given the name post-hcemiplegic poly myoclonus. The movements are neither 
choreiform nor athetoid, but are constant clonic contractions of most of the 
muscles in the limbs affected, not occurring synchronously, and the rhythm 
being about that of paral} r sis agitans (five per second). All of these move- 
ments indicate interference with motor conduction due to lesions in some 
part of the voluntary and inhibitory tracts. 

The following schedule of symptoms by Jacobi is useful in showing the 
diagnostic features of the different palsies: — 

Upper Extremity. — Deltoid: Absence of deformity, which is averted 
by weight of arm. Inability to raise arm. Sometimes subluxation. Fre- 
quent association with paralysis of biceps, brachialis anticus, and supinator 
longus. 

Lower Extremity. — Ilio-psoas: Eare except with total paralysis. As- 
sociated with paralysis sartorius. Loss of flexion of thigh. Limb extended 
(if glutei intact). 

Glutei. — Thigh adducted. Outward rotation lost. Lordosis on stand- 
ing. Frequent association with paralysis of extensors of back. 

Quadriceps Extensor. — Flexion and adduction of leg (if hamstrings 
intact). Loss of extension of leg. Frequent association with paralysis of 
tibialis anticus. 

Tibialis Anticus. — Often concealed if extensor communis intact. If 
both paralyzed, then fall of point of foot in equinus. Dragging point of 
foot on ground in walking. Big toe in dorsal flexion (if extensor pollicis 
intact). The tendons prominent. Hollow sole of foot (if peroneus longus 
intact) . 

Extensor Communis. — Nearly always associated with that of tibialis 
anticus. Toes in forced flexion. 

Peroneus Longus. — Sole of foot flattened. Point turned inward. In- 
ternal border elevated. 

Sural Muscles. — Heel depressed. Foot in dorsal flexion (calcaneus). 
Sole hollowed if peroneus longus intact; flattened if piralyzed. Point 
turned outward (calcaneo-valgus). 

Extensors of Bad'. — Lordosis on standing. Projection backward of 
shoulders. Plumb-line falls behind sacrum (unilateral). Trunk curved to 
side. Trunk cannot be moved toward paralyzed side. 

Abdominal Muscles. — Lordosis without projecting backward of 
shoulders. 



1 Starr. American Text-book Diseases of Children, p. 652. 



838 DISEASES OF THE NERVOUS SYSTEM. 

Rigidity and contractures are striking symptoms in almost all these 
palsies, and for this reason they often fall into the hands of the ortho- 
joedic surgeons, who are besought to remedy the rigidly-flexed elbows, 
wrists, knees, and the various deformities that interfere with locomotion. 
Adductor spasm in the thighs, causing cross-legged progression, is nearly 
constant in diplegia and paraplegia. Talipes equino-varus is the most fre- 
quent pedal deformity in hemiplegia. Rarely talipes equinus and talipes 
equino-valgus are to be found in hemiplegia. While rigidity with con- 
tracture is the rule in all of these forms of infantile cerebral palsy, occa- 
sionally, but very seldom, cases will be met with in which the muscles are 
all completely flaccid. The chief trophic disturbance encountered in these 
cases is retardation in growth of the paralyzed member. The paralyzed 
limbs do grow, but at a much slower rate than the sound extremities. 
Hence the disproportion is often very striking. The earlier the onset 
of the palsy, the greater is this disproportion. Another peculiarity noted 
is that the growth of the whole organism is to a certain extent inter- 
fered with, the injury to the brain seeming to stunt development and 
to prevent the patient attaining his normal stature. The patients are more 
or less undersized and dwarfed. Peterson describes a case in which the 
mother brought to him her two boys, twins, 6 years of age, for the exami- 
nation of the one affected. One was a tall, well-built lad; the hemiplegic 
boy was small-bodied and fully seven inches shorter than his healthy 
brother. In all of these cases the muscles of the paralyzed and undevel- 
oped extremities react normally to the faradic current. There is no re- 
action of degeneration. In many cases the affected limbs may be blue and 
cold, as in paralysis of the spinal type. A very rare phenomenon in these 
cases is a hypertrophy of the muscles, usually combined with athetosis. 

Asymmetry of face and skull have been observed. Peterson and E. D. 
Fisher have called attention to the flattening of the skull on the side op- 
posite the paralysis in infantile spastic hemiplegia. 

Differential Diagnosis. — From infantile spinal paralysis we can dif- 
ferentiate, by the presence of the exaggerated reflexes, the rigidity and 
normal reaction of the muscles. In cerebral palsy there is no actual atrophy 
in the limbs. "When the central neuron is involved, the inhibitory influence 
over reflex manifestation is lost; consequently there is an increased reflex. 
When the peripheral neuron is involved, the circuit being broken, the reflex 
is lost. There are no marked trophic changes. 

Prognosis and Course. — In diplegia and paraplegia due to intra-uterine 
or birth 1 lesions they rarely reach the third year. As a rule they die of 
marasmus in infancy. In hemiplegia, the prognosis is better. In most 
cases the paralysis may improve and the brain may not be seriously im- 



1 See article on "Erb's Paralysis or Birth Palsy in the Xew-born Baby." 



PLEUROPLEUIA. 839 

paired. If epilepsy appears in later life, we may suspect a previous infan- 
tile paralysis. 

The palsy affecting the face and the leg can usually be improved. 
Speech will also gradually return if improvement is noted. The late ap- 
pearance of epilepsy must not be forgotten. Sometimes the paralysis is 
present a year or more before the onset of the epilepsy (Peterson). 

Treatment. — If convulsions are present, the inhalation of chloroform 
or laughing gas is indicated. Anti-spasmodics, such as bromide of potas- 
sium or bromide of sodium, with or without chloral hydrate, can be given. 
General attention to the stomach and bow r els — and dietetic management 
is certainly indicated. Iodide of sodium is also indicated. Counter-irritants 
cause excitement and sometimes do harm. J. Madison Taylor advises 
against the use of counter-irritants. Electricity combined with massage 
is useful. The faradic interrupted current will do good by stimulating the 
muscles. The current should be used daily; besides careful massage 
(muscle kneading), passive movements are of great importance. This form 
of exercise should be resorted to and more good can oe done by this form of 
treatment than by all medication. We must not expect the bodily 
functions to return to normal until we have strengthened the body with 
restorative treatment, combined with fresh air, and by all means light 
nutritious food. 

Some cases will not yield to medicinal treatment, and here surgical 
procedure has been advised. Neither trephining nor craniectomy have been 
successful. Allen Starr reports in a recent paper that in fifty cases oper- 
ated, in these and allied conditions, the results were not encouraging. 

A child 3 years old was brought to my clinic at the New York Post-graduate 
Medical School and Hospital in 1894. It was suffering with backward development 
and had distinct evidences of cerebral palsy. There was a diplegic paralysis. The 
head was microcephalic. As nothing could be done by general routine treatment, it 
was decided to try surgical treatment. A craniectomy was performed by Dr. 
Seneca D. Powell. The child died. 

Two other cases known to me have been operated, and the surgical 
treatment in each has been disappointing. 

Pleuroplegia (Mobius'sche Kernschwund) . 

This is a congenital condition caused by a combination of abducens, 
facial, and hypoglossal paralysis. 

This condition is caused by nuclear defects, and the partial palsies 
are evidently due to lack of intra-uterine development. The following 
case illustrates this condition: — 

C. M. G., born May 4, 1898, was referred to me for diagnosis by Dr. Henry A. 
Bernstein. 

Family History. — It is the first child. The mother has bad two miscarriage^ 



840 



DISEASES OF THE NERVOUS SYSTEM. 



since the birth of this child. The parents are not related by birth. Syphilis can 
be positively excluded. 

Child's History. — She was breast-fed for three months; later received bottle 
feeding. When five months old it was noticed that the infant could not support its 
head. Dentition began at seven and one-half months. Did not walk until the third 
year. Had measles and also diarrhoea about this time and ceased walking, but began 
to walk again during the fifth year. Talking began when 5 years old. Could not 
connect words until 6 years old. Is inclined to constipation. Adenoids were re- 
moved when 3 years old. 

St. pr. — Now 7 years old. The heart sounds are clear and normal, although 
heart action is slow (bradycardia). The head moves normally. There is a funnel- 
shaped depression of the thorax, also a spinal curvature, pendulous belly, carious 
teeth, besides other symptoms of rickets. The nasolabial folds arc totally absent. 
There is an absence of expression — no difference in laughing or crying. The saliva 
flows out of the mouth. The eyes do not close during sleep (lagophthalmus) . The 
iris disappears under the bids in attempting to close them. There is an absence of 
the secretion of tears. No fibrillary contractions of the tongue are visible. The 
uvula is in the median line just as in the normal child. 

Treatment. — Restorative treatment consisting of proteid food and general 
hygienic treatment to improve the rachitis was ordered. 

Codliver-oil and phosphorus may be tried, as also large doses of iodide 
of sodium. Faradic electricity is indicated. 



Etiology. — This disease 



Pseudohypertrophic Paralysis (Muscular Pseudohypertrophy). 
We are indebted to Duchenne for an accurate clinical description of 
this condition. 

is usually found in children between the sec- 
ond and eighth years. It is more frequently 
observed in males than in females. There is 
no distinct cause of this disease. 

Pathology. — The pathological lesions 
noted are a fatty infiltration of the muscles, 
changes in the breadth and contour of the 
muscular fibers, and an increase in the inter- 
muscular connective tissue. 

Symptoms. — Motor-weakness is usually 
the first thing noticed. A child apparently in 
good health will complain of inability to walk. 
At the same time there will be an enlarge- 
ment of certain groups of muscles. In cases 
seen by me the muscles of the calves were 
almost as large as those of the thighs. Stew- 
art has reported cases in which the calves of 
the child were as large as those of an adult. 
The muscles most frequently affected are the 
deltoids, biceps, triceps, latissimus dorsi, and 
sterno-mastoids. 




Fig 



273. — Pseudohypertrophic 
Paralvsis. 



I am indebted to Dr. Dexter Ashle/ for the 
abov* illustratioa. 



PSEUDOHYPERTROPHIC PARALYSIS. 



841 




Fig. 274. 



Fig. 275. 




pseudohypebtrophic 
Paralysis. 

Fig. 274. — Note hyper- 
trophic condition of the 
muscles of the legs. Can- 
not stand without strong 
support. (Original.) 

Fig. 275. — Attempting 
to rise from chair. Com- 
pare atrophy of muscles 
of arms and spine with 
hypertrophy of muscles of 
legs. (Original.) 

Fig. 276. — Attempting 
to rise from floor. Can 
raise the body no higher. 
( Original. ) 



Fig. 276. 



842 DISEASES OF THE KERVOUS SYSTEM. 

Duchenne has found all of the muscles of the body l^pertrophied. 
After the hypertrophy disappears it is succeeded by an atrophic condition. 
There is less muscular irritability with faradic and galvanic currents. The 
patellar reflex is usually absent as the disease progresses. 

Case I. — A. L., 6 years old, boy. As a baby the mother noted that there was 
something the matter. Walked at 2 years of age. Child was very fat, and had a good 
appetite at that time. Now eats but little. 

Walks very erect, in soldier-like position, almost suggesting Pott's disease. 
Steps slowly. On table, first noted apparently strong muscular development of the 
back. Muscles of back, thigh, calves, apparently well-developed. Child rises from 
the floor with characteristic movements. Flat-footed. Cannot get up without roll- 
ing over, when reclining on back. Child looks to be in good health. Father says 
he is constantly growing weaker, slowly. Came to me for diagnosis, not having 
previously known the nature of the condition. 

Case II. — Jacob S., was first seen by me when 12 years old. Walking became 
impaired at the age of 6 years, gradually getting worse, so that to-day he cannot 
walk at all. The reflexes are absent. Sensation is impaired. The spinal muscles 
in dorsal region are atrophied. Gastrocnemii markedly increased in size. The 
extreme difficulty of rising from a sitting position is very characteristic. (Fig. 276). 
The loss of power in arms is quite marked also. A history of diphtheria is given 
just prior to the onset. 

Dr. L. S. Manson kindly referred this case to me. 

Prognosis. — The prognosis as a rule is bad. 

Treatment. — The treatment consists in restoratives. Massage may be 
tried. Such a case should always be sent to a neurologist to outline the 
future course of treatment. 

Facial Paralysis in the New-born. 

This condition is most frequently seen in the new-born after the use 
of the forceps. It is a peripheral paralysis resulting from traumatism. It 

is the result of pressure on the nerve near the 
exit through the stylo-mastoid foramen or where 
the facial nerve crosses the ramus of the jaw. 
The parotid gland gives little protection in the 
new-born. The paralysis is most frequently 
unilateral, as usually only one blade of the 
forceps causes injury. 

Fig. 277.— Facial Par- FACIAL PARALYSIS (Bell's PARALYSIS). 

alysis following Mastoid 

Operation. (Original.) This is frequently called post-operative 

palsy. This disease may follow mastoid opera- 
tion. It may also follow retropharyngeal abscess (Bokai). 

The disease is sometimes associated with tumor in the cerebellum. 
Prognosis and Course. — Great care should be exercised in expressing 




ABSCESS OF THE BRAIN. 843 

an opinion as to the outcome of a case of facial palsy. In one case seen 
by me after a mastoid operation a permanent palsy remained. I saw the 
case four years after the operation. 

Treatment. — This depends on the cause. Restorative treatment aided 
by massage and electricity should be tried. Unless some improvement is 
noted within a few weeks the outcome of the case will be serious. 



Abscess of the Braix (Cerebral Abscess). 

This condition is occasionally seen in children. 

Etiology. — There are two principal causes of this condition : first, 
traumatism — injury to the head by a blow or a fall, resulting in fracture 
of the skull or in abscess; second, from an extension of middle-ear abscess 
into the mastoid cells, so that an abscess of the cerebellum results. The 
infection is carried through the veins or usually along the lateral sinuses 
to the cerebellum. "Wagner reported a case of cerebral abscess in which 
thrush was believed to be the cause. 

The white substance of the brain is usually affected in this suppura- 
tive process. It is rarely seen in children under 1 year of age, but more 
frequently between the ages of 1 and 10 years. Out of 223 cases reported 
by Gower, 24 occurred between the ages of 1 and 9 years. Korner's statis- 
tics show that out of 77 cases of brain abscess, 25 were secondary to ear 
disease. 

In 38 out of 40 cases, according to Korner, the bone itself is 
diseased. 

Pathology. — Meyer reports a case of abscess which occupied an entire 
hemisphere. The pus found is usually greenish-yellow. At times the 
abscess may be encysted, in which case it is surrounded by a pyogenic mem- 
brane. Lalemand reports a case of abscess of the brain in which there was 
an escape of pus through the auditory meatus. "The most frequent seat of 
the abscess is, first, the temporo-sphenoidal lobe ; secondly, the cerebellum ; 
thirdly, the frontal lobes. Other locations are very rare. Abscesses are 
usually single. In size they vary from that of a cherry to an orange." 

"Abscess of the brain, as well as meningitis and sinus-thrombosis sec- 
ondary to otitis, begin, as a rule, at a point corresponding to that at which 
the inner surface of the bone is attached. The roof of the tympanum 
enters into the middle fossa, and the bony partition is sometimes as thin 
as writing-paper; it is for this reason that disease of the middle ear most 
often causes abscess in the temporo-sphenoidal lobe which lies on the fossa. 

The mastoid cells are separated from the posterior fossa by a thin 
layer of bone, and hence abscess, secondary to disease in that region, is 
often situated in the cerebellum. The extension of the disease to the brain 
is due to thrombosis extending from the diseased bone, or from the ear, 



844 DISEASES OF THE NERVOUS SYSTEM. 

through the veins which pierce the roof of the tympanum; only rarely is 
there a direct communication by a suppurating tract. In common with 
other forms of intracranial inflammation due to ear disease, abscesses occur 
more often on the right than on the left side." 

Symptoms. — If the child is old enough to complain, there will be 
headaches described over the affected area. Fever usually accompanies this 
condition. The temperature may rise to 10-i° or 105° F. in the beginning, 
although cases are reported where the temperature remains normal. Vom- 
iting usually accompanies this condition. At times in young children there 
are convulsions, coma, opisthotonos, and all s} T mptoms pointing to a men- 
ingitis. When distinct areas are affected, such as the motor areas, then 
paralysis of the extremities may take place. Optic neuritis is sometimes 
present. A choked disc can sometimes be made out by an ophthalmoscopic 
examination. If the bones of the cranium are thin then there is usually 
marked tenderness over the region of the abscess. 

A foundling/ eleven months old, was in a fair condition when first seen by the 
foster parents, who later adopted him. This infant subsequently developed sore eyes 
and still later had several bruises on the scalp which suppurated. In addition 
thereto he was emaciated and showed the evidence of both neglect and improper 
feeding. The infant with proper feeding and hygienic care developed into a bright 
healthy boy. He attended school and seemed in good health until his seventh year, 
when he showed signs of trouble Avith his head. Dr. W. B. Chapin, who attended him, 
suspected caries of the bones back of the ear. 

Dr. W. Freudenthal was called in consultation with Dr. Chapin to see the swelling 
behind the ear, which had developed during the previous eight weeks. The swelling 
was about the size of a large cherry, there was no pain on palpation and no spas- 
modic contractions. The swelling was located on the side of the head corresponding 
to the upper lobe of the ear. It was not reddened and fluctuated on palpation. Ex- 
amination of the ear showed no pathological condition. The drum membrane was 
normal. There was no tenderness over the mastoid. 

After waiting some time it was thought advisable to open the abscess. The 
abscess was opened by Dr. Freudenthal with general anaesthesia. Necrotic tissue 
was found, but the mastoid was intact, and it was impossible to probe the mastoid 
cells; however it was found that a small probe penetrated in the direction of the 
frontal lobe to the depth of 3 1 / 4 inches. Pus oozed from this opening. As this was 
evidently a case of cerebral abscess, the wound was dressed and the further operative 
procedures left to a surgeon. The temperature ranged between 99° and 1047 2 ° F. 
The abscess was on the right side of the head. Convulsions occurred on the left 
side of the body. Dr. A. Gerster was called in and diagnosed the case as a cerebral 
abscess. On the following morning an operation was performed. To be sure that 
the mastoid was not involved, part of the mastoid was opened. It was found normal. 
Two ounces of pus were evacuated from the abscess. The case ended fatally. 

Diagnosis. — This is usually made when suppuration of the middle ear 
existed prior to this attack. If opisthotonos, symptoms of coma, convul- 
sions, high fever, or vomiting follow an attack of acute or sub-acute otitis, 

1 1 am indebted to Mr. Saul Japha for the clinical history of this foundling. 



IDIOCY AND IMBECILITY. 845 

then an extension of the suppurative process should be suspected. At times 
the diagnosis will tax the ingenuity of the most expert aurist. 

Prognosis. — This is always grave. Our only chance for saving life is 
to resort to an early operation. 

Treatment. — The earlier surgical relief is instituted, the better will 
be the result. The medicinal treatment consists in relieving symptoms 
such as fever by means of an ice coil, and by active catharsis. Eelieve the 
nervous symptoms with the aid of large doses of bromide and chloral. Com- 
plete details of brain surgery are given by M. Allan Starr in his book on 
"Brain Surgery.' 7 

Alalia Idiopathica 1 (Backwardness ix Speakixg). 

When a child is in good health and does not learn how to speak, 
careful examination is necessary. In such cases it is important to exclude 
idiocy. Although some children do not speak before they are 2 or 3 years 
old, their general habits and mannerisms will easily show whether or no 
we are dealing with mental disease. 

The prognosis is excellent, although frequently parents will be very 
anxious and worried regarding the outcome. 

Treatment. — Persistent teaching will usually remedy this condition. 

Idiocy axd Imbecility. 

In idiocy we have a congenital absence of mentality and intelligence. 

In imbecility we have an arrested development or a partial arrest of 
development. 

Etiology. — According to Shuttleworth prolonged labor without in- 
strumental interference is the cause of idiocy in 29 per cent, of cases 
admitted to his asylum. Down states that of 2000 idiots examined by him 
there were symptoms of suspected inanition at birth in 20 per cent. This 
writer also states that disturbance of the mother's physical condition dur- 
ing pregnancy resulted in mentally deficient offspring in about 20 per 
cent. Griesinger states that "violent shock and grief during pregnancy 
appear not to be without influence as a cause of idiocy/' Consanguinity is 
a much disputed point. Some authors believe that blood relations in- 
variably have mentally deficient offspring. Other equally observant writers 
hold the opposite view. I have seen a case of idiocy in which the father 
and mother were first cousins. Children of intemperate parents, and chil- 
dren of syphilitic and tubercular parents are frequently found to be men- 
tally deficient. 



1 Read also, "Very Late Speaking," Part I, page 3. 



846 



DISEASES OF THE NERVOUS SYSTEM. 



Shuttleworth, a well-recognized English authority in this field, gives the 
following classification of idiocy : — 

Table No. 104a. 

CLASS A CONGENITAL. 

1. Microcephalic. 

2. Hydrocephalic (also non-congeni- 
tal). 

3. Scrofulous. "Mongol type." 

4. Sensorial (also non-congenital). 

5. Primarily neurotic. 

6. Paralytic (also non-congenital). 

7. Choreic (also non-congenital). 

8. Cretinoid: (a) sporadic, (6) en- 
demic. 

CLASS B — NON-CONGENITAL. 

fa) Developmental. 
9. Eclamptic. 

10. Epileptic. 

11. Syphilitic. 

12. Post-febrile (also accidental) . 
(o) Accidental or Acquired. 

13. Toxic. 

14. Traumatic. 

15. Emotional. 

16. From mixed causes. 

Symptoms and Diagnosis. — 

Great care must be taken in dif- 
ferentiating between backward- 
ness and idiocy. A child that is 
backward in development does 
not remain stationary in develop- 
ment, but progresses very slowly 
in comparison with children of 
the same age; for example, a 
backward child of 5 or 6 years 
will show the mental development of a child but 2 or 3 }-ears old. In such 
a case we deal with a slow mental progress, whereas an idiot shows a distinct 
arrest of development, both of body and mind. 

Down describes Mongolian idiocy in the following language : "The 
hair is not black as in the real Mongol, but of a brownish color, straight 
and scanty; the face is flat and broad, and destitute of prominence; the 
cheeks rounded and extended laterally; the eyes obliquely placed, and the 
internal canthi more than normally distant from one another (the epi- 
canthic fold often abnormally large) ; the palpebral fissure very narrow; 




Fig. 278.— Congenital Idiocy (Lillie B.). Age 6 
years. Delicate uutil 4 years of age. Did not walk 
until the fourth year. Mother cannot tell when 
difference in the two sides was first noted. There 
were no convulsions. The head measured 19 inches. 
There were strabismus, and deformed jaws. The 
mouth was constantly open. Right hemiplegia, 
more marked in upper extremity. Walks and runs 
around, but drags right foot. Contracture and 
spasticity present. Expression idiotic. Has never 
talked. Intelligence nil. Is restless and in nearly 
constant motion. (Case of Dr. A. C Cotton.) 



IDIOCY AND IMBECILITY. 



847 



the forehead wrinkled transversely, from the constant assistance which the 
levatores palpebrarum derive from the occipito-frontalis muscle in the 
opening of the eye; the lips large and thick, with transverse fissures; the 
tongue long, thick, and much roughened; the nose small; the skin has a 
slightly dirty, yellowish tinge, and is deficient in elasticity, giving the 
appearance of being too large for the body. 




Fig. 279. — Imbecile (Louie W.). Showing an- 
terior curve of the spine and general atrophy of 
all the muscles, especially those of the back and 
shoulders. (Original.) 



Fig. 280.— Imbecile (Louie W.). Showing 
normal position of head flexed on the chest. 
Can only lift head by raising chin with exten- 
sor muscles of hand and forearm. (Original.) 



"This type occurs in more than 10 per cent, of cases ; they are always 
congenital idiots ; they have considerable power of imitation ; they are 
humorous; they are usually able to speak, the co-ordinating faculty is 
abnormal; the circulation is feeble; the improvement which training 
effects is greatly in excess of what would be predicated if one did not 



848 



DISEASES OF THE NERVOUS SYSTEM. 



know the characteristics of this type; the life-expectancy is, however, far 
below the average, and the tendency is to tuberculosis." 

These children are usually found to be deaf, blind, or to have some 
deformity of the mouth, nose, hands, or feet. I have seen cases of this 
kind in my service at the German Poliklinik, of New York, and also re- 




Fig. 281.— Imbecile (Louie W.). Showing posi- 
tion assumed in walking. Cannot stand on feet. 
(Original.) 



Fig. 282.— Imbecile (Louie W.). 
drop wrist and foot. (Original.) 



Showing 



member seeing this form of disease at the Children's Klinik of Dr. Hugo 
Neumann, at Berlin. This disease usually ends fatally. 

I allude to infantile amaurotic idiocy (on page 849). Other forms 
of mental impairment are described in detail (see article on "Sporadic 
Cretinism," page 760). 



INT.WTIl.K AMAUROTIC FAMILY [DIOCY. 849 

Am Imbeciij Bating Microcephaly \m> Pseudo-muscular Atrophy. -Loui« 
\\ .. 5 years old. was referred t<> me through the courtesy of Dr. L. s. Manson. 

Previous History. — This child was born at full term, natural labor, no forceps. 

llt> was breast-fed about La months; could not stand, walk nor talk until 1 years old. 
Dentition began during the ninth month, which was very early in this family, a- all 
the other children teethed at fifteen months. He had measles when 2 year- old. 
influenza and pneumonia when 3 years old. The boy lias an unusually small skull, 
lti inches in circumference] the norma] circumference at this age i- about 21 inches. 

Family History. — The mother had been married twice., had six children with the 
first husband and five with the second. Three children died of scarlet fever. The 
rest of the children are strong- and healthy. There is no family history of idiocy or 
nervous disease on either father's or mother's side. 

The mother first noticed trouble when the child was 2 years old. when he 
began to go about on his knees, having never walked on his feet. He has no power 
in the hands or feet: speaks very little,, voice tremulous. Tic of small muscles of 
chin: knee-jerk both present. There is great muscular weakness of the lower ex- 
tremities and muscles of the back. There was drop-wrist and foot and universal 
wasting of the muscular sy>tem without marked trophic change-. Normal position of 
head is that of flexion on chest and can only lift head by raising chin with extensor 
muscles of hand and forearm. Fibrillary twitching of all the muscles in hands not 
amounting to athetosis. 

IXFAXTILE AmAUEOTIC FAMILY IDIOCY. 

This peculiar condition has attracted considerable attention in recent 
years. In 1881 Tay. of England, described a case of symmetrical changes 
in the macula lutea. The child could not sit erect and was backward men- 
tally. John Claiborne, reviewing this subject in 1900, refers to the above 
case, and says : — 

"At the first examination the optic disc was normal, but at the macula 
there was a white, more or less round area, in the center of which was a 
brown spot. The picture was similar to that seen in embolism of the 
central artery of the retina. Tay at first thought it was a congenital 
change. Five months later he noticed the optic disc was atrophied. Three 
months later he observed 3 other cases in the same family. In all the 
ophthalmoscopic picture was the same, and all these persons died before 
the end of the second year of the disease. During the years 1885 and 
1886 the same ophthalmoscopic picture was described by Magnus. Knapp, 
and others. In 1887 Sachs reported a case which impressed him as being 
one of idiocy; this was particularly interesting on accouut of the changes 
observed in the cortical cells. The family character of the affection was 
suggested to him after observing 4 cases in two families. Kingden, of 
England, published a case and showed a picture which eye surgeons said 
belonged to the disease which Sachs had elucidated. In 1898 Sachs re- 
viewed the subject, tabulating 29 cases." 

A. Jacobi reported 3 cases of this form of idiocy to the American Ped- 
iatric Society in 1898. 

r.4 



850 DISEASES OF THE NERVOUS SYSTEM. 

Pathology. — Sachs states that the external configuration of the brain 
exhibits a distinct picture of a lower order of development. It is difficult 
to state whether the changes were to be regarded as primary degenerations 
or due to an arrest in development. 

Symptoms and Diagnosis. — There is "a milky-blue or white optic disc 
with bright cherry-red center occupying the place of the macula lutea." 
Nystagmus is frequently present. Hydrocephalus has been reported asso- 
ciated with this condition. The weakness of the extremities increases slowly 
until diplegia appears. In such cases the optic symptoms and idiocy are 
pronounced, and from these two conditions alone the diagnosis can be 
made. The voluntary muscles are relaxed, especially those of the ab- 
domen. Death usually comes at the end of the second or third year, 
although the disease may last years. The child is totally blind. 

Treatment. — Xo treatment has as yet modified or benefited these 
children. 

Concussion" of the Brain. 

We frequently see children who have fallen down a flight of stairs, or 
with apparently as severe symptoms, will recover. The following case 
illustrates concussion of a mild ty-pe which recovered : — 

Case I. — A boy, 7 years old, rolled down a flight of stairs. I saw him about 
one hour after his fall. There was nausea and vomiting. Some slight abrasions of 
the skin were present, and a scalp wound one inch in length which required a stitch. 
The temperature was 100° F. The boy was put to bed. I saw him about twelve 
hours later. He was perfectly normal and complained of intense hunger. On the 
following day the boy was apparently well. 

Case II. — Severe Concussion of the Brain. — Child S. was seen by me through 
the courtesy of Dr. E. D. Lederman, with the following history: He was in his fourth 
year, bottle-fed during infancy, and excepting an occasional attack of dyspepsia, ha I 
always enjoyed good health. 

Present Condition. — Three days before I saw him he fell and struck his heal 
violently on the pavement. Six hours later severe vomiting set in. During the night 
following the fall he was feverish and moaned continually. On the following day 
when Dr. Lederman saw him the temperature was 103° F. The child seemed to be 
dazed and in a stupor at times. He was very thirsty. There were marked evidences 
of clonic and tonic spasms in the muscles of the body. A laxative was ordered. The 
gastro-intestinal tract was cleaned and an ice-bag applied to the head. These same 
symptoms continued, the fever rose to 105° F. and was not easily reduced. When I 
saw him in consultation with Dr. Lederman there were spastic conditions of the 
muscles of the arms and legs. There was marked rigidity of the spine. The sterno- 
cleido-mastoid muscles were rigid. There was marked opisthotonos. Severe photo- 
phobia. The pupils were dilated and did not respond to a strong light. The 
Babinski reflex was present on the right side, but not so positive on the left side. 
When moved about the child moaned as though in pain. A tache cerebrale was also 
present. The diagnosis of concussion and traumatic basilar meningitis was made. 



INSOLATION. 851 

A lumbar puncture waa made and almost one-half ounce of turbid (milky) cerebro- 
spinal fluid was withdrawn. The child passed urine involuntarily (evidently due to 
bladder paralysis). The case ended fatally. 

Insolation (Heat-stkoke: Sunstroke). 

This condition is most frequently seen in midsummer. It sometimes 
occurs in perfectly healthy children who are exposed to the direct rays of 
the mid-day sun. I have frequently seen cases of sunstroke in feeble chil- 
dren who were playing in the shade. Children with lowered vitality and 
convalescents from some severe illness, such as diphtheria or pneumonia, 
are more prone to be affected by intense summer heat. 

Pathology. — Intense cerebral hyperemia and an intense engorgement 
of the veins throughout the body are the usual lesions seen in this con- 
dition. 

Symptoms. — A child in apparently good health in midsummer will 
suddenly show intense fever. The temperature reaches as high as 104° 
or 105° F. in many instances. There is a corresponding increase in the 
pulse-rate. The pulse may be as high as 1G0 or 180. The face is usually 
flushed. The head is hot. There is a throbbing of the blood-vessels very 
apparent. The child may be unconscious and muscular twitchings may be 
noticed. In severe prostration there may be delirium and convulsions. 

The pupils are usually contracted, although they may be dilated, and 
the eyes intensely congested. Sometimes vomiting and diarrhoea may ac- 
company the symptoms above mentioned. 

The following illustrates the manner in which heat-stroke occurs 
in Xew York City : — 

A child will awaken in a normal condition,, eat its breakfast and play as usual. 
After several hours hard playing and exposure to the sun's rays, the child will be 
exhausted. If a careless mother or nurse permits the child to continue its exposure 
to the direct midsummer heat, then prostration with the above noted symptoms will 
be noticed. In some cases brought to my clinic, the head is hot and the hands and 
feet are cold. If the sunstroke takes place soon after feeding, then violent gastric 
symptoms usually occur. 

Prognosis. — The prognosis depends upon the vitality at the time of 
sunstroke. We must differentiate this condition from meningitis. The 
suddenness of the attack following exposure to the sun will usually aid 
in making a diagnosis. The majority of cases seen by me recovered. Occa- 
sionally a fatal case was encountered, especially in bottle-fed infants. 

This infant (Fig. 2S3) brought to my clinic July. 1900. weighed 5 pounds 6 
ounces. He was a bottle-fed infant, reared on condensed milk. He was nine weeks 
old. Vomited after each feeding, had greenish mucous, sour smelling stools, every 
half hour and oftener. There was eczema between the thighs from excoriation and 
acid stools. The child weighed 6 V 2 pounds at birth, and was a full-term baby. 



S52 



DISEASES OF THE NERVOUS SYSTEM. 



The child wa^ pulseless. The extremities were cold and covered -with a clammy 
perspiration. The temperature was subnormal — 97° F. The fontanel was de- 
pressed. The heart sounds were barely audible. The mouth, tongue, and lips were 
very dry: food and water were refused. Spirits of camphor. 5 drops, was injected 
hypodermic-ally; a mustard foot-bath was ordered. The child died fifteen minutes 
later. 




Fig. 283. — Insolation (Heat Stroke). Type of mid-summer cases in Xew 
York City. (Original.) 



Diagnosis. — Cholera infantum, marasmus, due to malassimilation of food; im- 
proper food to commence with. Extreme heat caused heart failure and general pros- 
tration. 

Treatment. — A tub-bath, temperature 90° ¥., gradually decreased to 
70° ¥., duration five minutes, is advisable. An ice-bag should be applied 
to the head. If consciousness has been restored, the child should be al- 
lowed to rest ; if not, then we can restore the circulation to relieve cerebral 
hyperemia by giving a mustard foot-bath for several minutes until the skin 
is reddened. The rectum and colon should be flushed with a hot saline 



INSOLATION. #53 

solution at a temperature of 110° F. ; this will stimulate diuresis besides 
cleansing the bowel. One-drop doses of aromatic spirits of ammonia with 
water may be given every 15 minutes. 
If the child can swallow then: — 

IJ Bromide of sodium 10 grains 

Chloral hydrate 3 grains 

should be given to a child 5 years old. This can be repeated every hour 
until a sedative effect is produced. In some cases (comatose) it may be 
advisable to inject per rectum : — 

I£ Bromide of sodium 15 grains 

Starch water 1 ounce 

Cold water should be given by mouth, with several drops of diluted 
hydrochloric acid. Peptonized milk, thin soups, and broths may be given 
every few hours. Liquid peptonoids can be tried if food is rejected. 



PARTX. 

DISEASES OP THE EAR, EYE, SKIN, AND ABNORMAL 

GROWTHS. 



CHAPTER I. 
DISEASES OF THE EAE. 

Acute Catarrhal Otitis Media. 

Acute catarrhal otitis media arises in the great majority of cases from 
extension of an inflammatory process by way of the Eustachian tube. 

Etiology. — Burkens found 104 deaths in 33.107 ear cases, and Eandall 
15 in 5000, giving a percentage of three-tenths of 1 per cent, from intra- 
cranial disease. 

Schwartz records 30 deaths in 8425 ear cases, or 0.35 per cent. The 
death rate from purulent ear diseases, compared with all other diseases 
treated, was shown in Guy's Hospital, in London, some years ago. to be 
57 deaths among 9000, two-thirds of 1 per cent; 40,073 autopsies in the 
Vienna General Hospital showed 232 deaths from otitic complications, i.e., 
0.58 per cent. The majority of these deaths occurred in the course of 
chronic suppuration of the middle car, complications in the acute stage, 
with the exception of mastoiditis, being less frequent. 

Naso-pharyngeal disease, especially the infectious diseases, such as 
measles, scarlet fever, influenza, and diphtheria, are frequently fol- 
lowed by otitis. The ease with which pathogenic bacteria can cause an 
inflammatory extension from the nose into the Eustachian tube is now 
recognized. Children of the lymphatic and rachitic types are more sus- 
ceptible to these infections. 

When a catarrhal process limits its attack to the lower portion of the 
middle ear chamber, the disease may run its course without becoming 
purulent. When, however, the upper part or tympanic attic is involved, 
we are more apt to find that the infection assumes a suppurative type. It 
is in this class of cases that complications arise and extension to the mas- 
toid cells by way of the aditus soon follows. 

Bacteriology. — Observers have found that even in the normal tym- 
panic cavity, pathogenic bacteria exist. Consequently any deviation from 
the normal process in this region predisposes the individual to a purulent 
infection. A passive congestion of the tympanic mucous membrane due to 
(854) 



PLATE XXIX 




Normal Mucous Membrane of the Middle Ear in the New-born. 




Inflammation of the Mucous Membrane of the Middle Ear. 
Section of infiltration with polypoid excrescences. 



• 






/ .\ V' 



an v ■>..:.;. ;x v ,- 
few '^ ^ ■" 







K , * ! 



Section of the Vessel of the Mucous Membrane Containing Streptococcus 
Pyogenes. (After S. Weiss.) 



A( I IK CATARRHAL OTITIS MKDIA. 



855 



cardiac, renal, naso, or nasopharyngeal disease, must be considered a 
potent factor in the production of a suppurative otitis. Staphylococci, 
diplococci, and streptococci have been found in the naso-pharyngeal Bpace, 
and it is reasonable to suppose that these micro-organisms are apt to find 
their way into the Eustachian tube and tympanitic cavity even under nor- 
mal conditions. 



160 
150 
1*0 
130 
120 
HO 
100 
90 
80 
70 
60 
50 
40 


106 
105 








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illilinii 


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Fig. 284. — Complication of Scarlet Fever seen in my service at Riverside Hospital. 

(Original.) 



A study of this case,, in which both ears were discharging, is interesting. The 
temperature was only 99 2 / 5 ° F. in the rectum. This proves that we must always be 
on the lookout for suppuration of the middle ear in the acute infectious diseases. 

Pathology. — We must bear in mind that the ossicular chain is sur- 
rounded or enveloped by folds of mucous membrane, and when this tissue 
becomes engorged drainage from the attic is difficult. Consequently our 
incisions through the upper and posterior portion .of the membrane in acute 
otitis should be deliberate and somewhat heroic, otherwise we will not 
accomplish the object in view, i.e., drainage from that portion of the middle 
ear which is most likely to be followed by disease of the mastoid antrum 
and cells. 

Symptoms. — Two prominent symptoms are always present; one is 
pain and the other fever. The infant is usually very restless, rolling the 
head from side to side on the pillow and rubbing the hand over the affected 



856 DISEASES OF THE EAR. 

ear. At times the nose and throat will also be inflamed. Local tenderness 
can usually be made out on pressure. The examination of the middle ear 
with the speculum should always be made by one skilled in this work. 

Symptoms of meningitis are frequently present and will disappear 
when proper treatment for an otitis is instituted. I have frequently seen 
a case of persistent high fever, during the course of a scarlet fever, suddenly 
improve after the drum-membrane was incised. The temperature ranges 
between 100° and 105° F. A distinct rise of temperature does not always 
accompany this condition as is usual in other inflammatory conditions. 

Diagnosis. — This is easily made by one skilled in examining the ears. 
When a doubt exists the safer plan is to call in an aurist for an opinion. 
The neglect of this precaution may prove a serious matter, as deafness may 
follow. 

Prognosis. — The prognosis is reasonably good. 
We must not be too positive in giving a good prog- 
nosis, as sometimes fatal results follow the extension 
of the inflammatory condition from the middle ear 
into the brain. 

Treatment. — Prompt drainage by an early inci- 
sion through the bulging membrane is the treatment 
indicated. To further drainage under such condi- 
tions it is wise to douche the ear with hot antiseptic 
solutions at a temperature of 108° to 120° F., using 
a return flow cannula. It has been claimed that the 
higher the temperature of the douche, the greater 
F . oo-^Ir 113 ^ . the possibility of absorbing the threatening mas- 

toiditis. 
Prophylactic Treatment. — As a soothing and prophylactic agent after 
incision or even before surgical intervention is indicated, a carbolized glyc- 
erine solution acts well in a number of these cases. In a very young 
child a 2 per cent, solution may be instilled into the ear after the same has 
been cleansed with a douche, every two hours. This may be increased in 
strength as the age of the patient progresses. Oily combinations should 
never be used as local agents in aural disease. They are apt to become 
rancid, and as the middle ear is an excellent incubator, affording bacteria, 
plenty of heat and moisture, infection rapidly occurs. 

General Treatment. — Peroxide of hydrogen or dioxygen is a valuable 
cleanser and deodorizer when the perforation of the membrane is large. 
The same remedy may cause extension of a purulent otitis if the aperture 
in the drum is small, and the liberation of its oxygen causes sufficient 
pressure to force the purulent foci backward through the aditus. Bulging 
of the upper portion of the membrane with a protrusion of the superior 
and posterior walls of the external auditory meatus, together with tender- 







ACUTE CATARRHAL OTITIS MEDIA. 857 

Qess over the mastoid antrum or tip, with some elevation of temperature, 
occurring during the course of an acute otitis, are indicative symptoms of 
mastoid involvement. Extensive disease of the mastoid cells may exist 
without the slightest rise in temperature, especially if the acute stage of 
the inflammatory process has passed by. 

"We may safely assume that in all cases of catarrhal otitis the mucous 
membrane lining the mastoid antrum is involved simultaneously with that 
of the middle ear, as it is part of the same tissue. For this reason blood- 
letting, done under aseptic precautions, should be carried out as near the 
cavity as possible; therefore, an internal "Wilde's incision carried through 
the posterior superior quadrant of the membrane is certainly a rational 
procedure. 

Eestorative treatment such as iron, codliver-oil, Fowler's solution, be- 
sides concentrated foods, must be remembered. Unless we assist the nu- 
trition of the body we cannot expect to cure the disease. If the symptoms 
increase in severity and the temperature persists, the dangers associated 
with mastoiditis must be remembered, and the skill of an otologist or a 
surgeon will be required. 

Mastoid Operation ox Ixfaxts axd Childrex. 

In operating on infants and children it is important to remember cer- 
tain points wherein they differ from adults. These briefly mentioned are 
the following: — 

At birth, in the mastoid the antrum exists as the only cavity, about 
the size of a small pea: the process is not formed until after the end of 
the first year, and the pneumatic spaces not until puberty. 

There are also frequently dehiscences filled with fibro-cartilage as the 
squamo-mastoid suture is not ossified at birth. So when making the pri- 
mary incision, the knife must be used gently until the periosteum is 
reached, and this likewise must be raised with the greatest care to prevent, 
in such cases, the instruments slipping into the cranial cavity. 

In curetting after opening the mastoid, it must be borne in mind that 
the bone tissue in childhood is soft, so that healthy tissue need not be 
sacrificed unnecessarily. 

The Operation. — During the operation, strict antisepsis must be ob- 
served. The space around the mastoid for two or three inches beyond 
should be shaved and made surgically clean. The auditory canal should 
be irrigated with a bichloride solution of 1 to 1000. Then under com- 
plete anaesthesia, with a scalpel, curvilinear incision should be made from 
end of the mastoid close to the insertion of the auricle to about one-half 
inch of its upper border, down to the periosteum. This is then separated. 

The bleeding is controlled either by clamping vessels, or with gauze 
wrung out of hot water. An Allport retractor or one of its modifications 



858 DISEASES OF THE EAR. 

should then be used, which not only answers the purpose of its name, but 
also stops the oozing. The parts should be separated with the auricle 
held forward so that the posterior and superior walls of the auditory canal 
and the whole field of operation is exposed to view. 

If the bone is bathed in pus this is wiped away and any perforation 
is examined with a probe. The opening is enlarged, either with a spoon 
or rongeur. Should no perforation or sinus exist, then the antrum should 
be opened either with a flat chisel or gouge and a mallet. The supra- 
meatal triangle is above the antrum. This is made by drawing one line 
horizontally with the superior border of the auditory canal, a second ver- 
tical one with the posterior, and a base line corresponding with the curvi- 
linear line between these points. 

The chisel should be used gently and tangential, and the bone chipped 
away in small sections, always working downward, forward, and inward. 
A probe should be used to determine from time to time whether the antrum 
has been entered, and also to examine the cavity made. 

As soon as an opening has been made, a rongeur should be used to 
enlarge it, and then thoroughly cleaned out with a Volkman's spoon. The 
space leading from the antrum to the roof of the tympanum, that is, the 
aditus and attic, should be carefully cleaned out with a small curette. The 
antrum should then be carefully extended backward until the lateral sinus 
is exposed and inspected as to whether its appearance is healthy. Its pres- 
ence can be determined by its bluish appearance and the soft feel to the 
probe. All granulations and soft tissue having been cleaned out, the parts 
are gently irrigated with a bichloride solution of 1 to 5000, normal salt 
solution, saturated solution of boric acid, or sterile water if considered 
necessary. The wound is then wiped dry, the upper and lower ends can be 
stitched together, and the rest packed somewhat lightly with iodoform 
gauze. Bury this gauze; that is, do not let it project; then over this 
draw the parts together and apply layers of sterile gauze, absorbent cotton, 
and a bandage. 

After-treatment. — Unless pain or a rise in temperature occurs, it is 
frequently not necessary to change the dressing for five or six days. Usually 
there is no discharge in the auditory canal ; if there is, it is gently irrigated 
or wiped out. For the mastoid wound, a dry wiping is all that is neces- 
sary usually, and a dressing of sterile gauze used lightly packed. This can 
be changed every two or three days. Granulation tissue of course must be 
cauterized. 

Accidents During the Operation. — Wounding the lateral sinus may 
cause a profuse haemorrhage. If the bony cortex has been sufficiently re- 
moved, the sinus may be plugged with iodoform gauze and the operation 
completed. The sinus whenever exposed should be kept covered with iodo- 
form gauze separate from the rest of the cavity to prevent infection. If 



ACUTF CATARRHAL OTITIS MEDIA. 



859 



the vessel should not be sufficiently freed from the bony covering, the 
bleeding may prevent the completion of the operation. 

Exposure of the Dura. — If carefully dealt with, this is not a matter 
of much importance, if the part is kept covered with iodoform gauze inde- 
pendent of the rest of the wound. If the dura should be wounded it should 
be opened, cleaned, and sewed up with fine catgut sutures. 

Facial Paralysis. — In operating, this condition can be prevented by 
not interfering with the lower two-thirds of the posterior wall of the 



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Fig. 286. — A Common Type of Acute Mastoid Inflammation Following 
Influenza. There was a double otitis before the extension to the mastoid 
cells. Note the fever curve following the operations. Case recovered. 
(Original.) 



auditory canal and the facial nerve will escape injury. Where it has been 
slightly injured, the function of the nerve is usually restored within four 
to six weeks. 

Francis M. C, 1 year old, suffered with gastric disturbance, poor appetite and 
symptoms resembling colic. His bowels moved sluggishly, the stool was greenish and 
contained mucus and undigested particles of casein. He emaciated owing to the 
non-assimilation of food. From the history I learned, that the child has had fever 
accompanied by catarrh of the nose and a general bronchitis for the last four weeks. 
The examination of the body showed a decidedly rachitic thorax and distended 
abdomen: retarded dentition and general backwardness in development. There was 
no evidence of pulmonary disease. The heart-sounds were feeble and a haemic 
murmur was distinctly heard at the apex of the heart and also in the vessels of the 
neck. The child perspired very freely. The temperature was 102.4° F., pulse 140, 
respiration 28. The throat showed enlarged tonsils and also adenoid vegetations. 
This latter condition was reported by Dr. Charles D. Manson. Both ears were dis- 
charging. The child was very restless, moaned and fretted continually and did not 
sleep at night. My diagnosis was influenza, subacute gastric catarrh, rachitis, and 
mastoid involvement. Dr. Edward Dench saw this case at my request and corrobor- 



S6Q DISEASES OF THE EAR. 

ated the diagnosis. The temperature rose to 103.6° F. The right mastoid was 
opened by Dr. Dench at the New York Ear and Eye Infirmary. The temperature 
came down by lysis to normal. Three days later, while the child was doing quite well, 
the temperature again rose to 103.6° F. A left mastoid was suspected, and accordingly 
the second operation was performed. On the day following the operation the tempera- 
ture rose to 104.2° F., and an acute milk infection was suspected. With the aid of 
mist, rhei et sodii and a diet of whey only, at intervals of three or four hours, the 
stomach symptoms subsided, and four days later the child was removed from the 
hospital to its home in a normal condition. With careful asepsis both wounds healed. 
The child gained in weight and within one month had entirely recovered. 

Foreign Bodies in the Ear. 
Insects, bugs, cotton, beads, and pieces of pencil are frequently found 
in the meatus. When beans or peas remain they swell and cause painful 
pressure symptoms. The specialist should invariably be consulted rather 
than risk the danger of traumatism in unsuccessful attempts at removal. 
If a live insect or bug is in the middle ear, pour water, oil, or alcohol into 
the ear. If the insect is not dislodged by this means try Allen's foreign 
body forceps. 

Thrombosis of Cerebral Sinuses. 

There are two conditions usually seen in children; first, primary, 
where there is a general malassimilation of food, such as we find in ma- 
rasmus. This is also called marasmic thrombosis. Second, a secondary 
condition due to a local disease, such as injury to the bone or ear. 

Primary thrombosis is confined to the superior longitudinal sinus. 

Symptoms. — (Edema of the scalp on the side of the head and fore- 
head. At times there is epistaxis. The fontanel is usually bulging or 
distended. If the clot extends into the internal jugular then the external 
jugular will be overfull and the thromboid vein can be felt as a very hard 
band. 

Secondary Thrombosis. — This is usually due to suppurative otitis 
media. It usually affects the lateral sinus. It may also follow suppuration 
in the eyes or nose, or follow erysipelas. 

Cavernous sinus may result from the lateral or petrosal sinuses. It 
may be due to extension from the ophthalmic veins, such as is found in 
phlegmonous inflammation within the orbit. 

The special symptoms are exophthalmia, ptosis, oedema of the lids 
and of the root of the nose, also paralysis of the sixth and other ocular 
nerves. 

Thrombosis of the veins of Galen, leading to effusion into the ven- 
tricles, has occurred as a fatal complication of scarlet fever. "The throm- 
bosis may be brought about by direct extension from the inflamed bone, or 
by extension by accretion of a septic clot from the veins of the mastoid 
cells, which open into the lateral sinus." 



CHAPTER II. 



DISEASES OF THE EYE. 



Acute Catarrhal Conjunctivitis. 

This condition is usually associated with infectious diseases. As a 
rule it is found in coryza, the acute exanthemata, influenza, and the usual 
infections due to pathogenic bacteria in the atmosphere. 

General Plan of Cleaning the Eye when Secretion Exists. — The eyes 
should be thoroughly cleansed with a pledget of cotton clipped in lukewarm 
water. Then use a drop or two of a solution of cocaine : — 

I£ Cocaine hydrochlorate 10 grains 

Salicylic acid 7a grain 

Distilled water 1 ounce 

M. Drop into the eye 3 times a day. 

After instilling the cocaine, a few drops of a 2 per cent, argyrol 
solution should be dropped on the eyelid. The irritating secretions 
should be wiped away as frequently as possible. A weak solution of bichlo- 
ride of mercury, 1 to 5000, applied on cotton, will best serve to cleanse the 
eye. It should be used at a temperature of 100° F., hourly if necessary. 

A solution of borax: — 

I£ Biborate of soda 4 parts 

Distilled water 100 parts 

Or:— 

I£ Argyrol 1 part 

Distilled water 100 parts 

are very good cleansing remedies. 

Peroxide of hydrogen, 2 one-half strength, is recommended by Stephen- 
son, to be used three times a day. 

Atropia is simply mentioned to be condemned. Protargol and largin 
stain the conjunctiva and are useless. To prevent the lids from gluing 



1 The correction of Errors of Refraction, such as astigmatism by means of eye- 
glasses, and the treatment of strabismus, should only be undertaken by the specialist. 
The reader is referred to special works on Diseases of the Eye for particulars regard- 
ing these conditions. 

2 A good preparation on the market is called dioxygen. 

(861) 



862 DISEASES OF THE EYE. 

together the yellow oxide of mercury ointment should be applied two or 
three times a day : — 

I£ Yellow oxide of mercury (5 per cent.) 1 part 

Vaseline 10 parts 

Lanoline 10 parts 



Pink Eye. 

This form of acute Ophthalmia is similar to the one just described. It 
is very communicable and most probably transmits infection by a specific 
organism. 

Weeks 1 was the first to describe a definite micro-organism causing 
this disease. The Weeks bacillus is short and has rounded ends. It 
stains very easily with methylene blue. It is intensely contagious and 
spreads rapidly, especially in schools. Children under fifteen years are 
especially susceptible. 

The diplo-bacillus of llorax was described by him in June, 1896, in 
the Annal de rTnstitut Pasteur. The inflammation is frequently due to 
the presence of the diplo-bacilli. The inflammation usually begins in one 
eye and infects the other a few days later. Its course may be either chronic 
or acute. 

Pxeumococcus Ophthalmia. 

This disease is frequently seen in new-born children in which the 
lachrymal sac suffers. 

Grifford 2 described an epidemic in Omaha where several distinct out- 
breaks took place within a few years. 

Veasey 3 states that the pneumococcus is the most frequent cause of 
ophthalmia in Philadelphia. The bacteriological examinations of the or- 
ganisms are very easily made. A cover glass smeared with the pus, stains 
well with methylene blue. Under the microscope there are diplococci, 
cocci, and chains devoid of capsule. 

Infection of the conjunctiva sometimes occurs. This is frequently 
the result of impetigo contagiosa of the face or scalp. Infected secre- 
tions transmitted to the eye by the fingers usually set up this inflamma- 
tion. Little girls frequently transmit vaginal discharges on their fingers 
and thus cause infection. The common cocci of suppuration, namely, sta- 
phylococcus pyogenes aureus, albus, and citrous, are usually found in this 
discharge. 



1 Archives of Ophthalmology, 1886, No. 4, p. 441. 

-Grifford: Archives of Ophthalmology, vol. xxv, 1896, p. 314. 

3 Veasey: Archives of Ophthalmology, vol. xxxviii, 1899, p. 301. 



MEMBRANOUS CONJUNCTIVITIS. 563 

Treatment. — Clean the eye by dipping small pledgets of absorbent col- 
ton into lukewarm water, or dip the eotton into a 2 per eent. solution 
of borax. A medicine dropper can be filled three or Jour times with a 
solution of: — 

B. Formalin ' 1 to 2000 

Sig.: Wash or bathe the eye with thin formalin solution every four hours. 

Very hot water applied on pledgets of sterilized cheese-cloth will re- 
duce the inflammation of the lids. In other cases, cold lead and opium 
wash will be very soothing and have a similar effect. We can prevent the 
lids from sticking together by applying vaseline at night. 

Purulext Ophthalmia (Oppithalacia Xeoxatoruae). 

This is a purulent conjunctivitis of the new-born infant. It may be 
seen several hours, or sometimes appears several days, after birth. The 
amount of pus secreted is very large. When the lids are separated pus 
will be liberated. 

Etiology. — It is usually caused by an infection in the maternal pas- 
sages containing the gonococcus during labor. The pneumococcus has also 
been found in some cases. These pathogenic bacteria are carried directly 
into the eye, either by the secretions or by means of infected sponges or 
towels. Bacteriology has proven that all causes excepting distinct germ 
infection must be eradicated. 

Symptoms. — The lids appear red and swollen. The upper lid fre- 
quently overhangs the lower and the infant is unable to open the eyes. 
Stephenson states that 10 per cent, of children so affected remain totally 
blind. Of 446 cases of ophthalmia occurring in the practice of seven phy- 
sicians quoted by Stephenson, gonococci was found in 72.83 per cent. In 
Stephenson's own cases, out of 45 affected, 30 showed evidence of the gono- 
cocci, or G6.5 per cent. 

Preventive Treatment. — The Crede method is now universally used. 
As soon as the infant is born and the face wiped clean, the following solu- 
tion is dropped into the eye: — 

IJ Nitrate of silver solution 2 per cent. 

Sig. : It is best to let it fall from a medicine dropper on the eyeball. A slight 
inflammatory reaction is occasionally seen and if treated with a cold solution of 
formalin, 1 to 2000, disappears quickly. 

Membraxous Coxjuxctivitis (Diphtheritic Coxjuxctivitis). 

We occasionally see membranous patches on the surface of the con- 
junctiva. This membranous deposit is sometimes distinctly diphtheritic, 



1 Formalin is a 45 per cent, solution of formaldehyde. Formaldehyde itself is a 
gas and a strong escharotic. 



864 DISEASES OF THE EYE. 

a culture taken showing the presence of the Klebs-Loeffler bacillus. To 
differentiate clinically between the diphtheritic and non-diphtheritic type 
is sometimes impossible. I have seen membranous conjunctivitis at the 
Willard Parker Hospital in which the disease clinically resembled diph- 
theria and still the Klebs-Loeffler bacillus was absent. In one case seen 
by me the streptococcus alone was present. The clinical history of the case 
is an important guide in the diagnosis. If another case of diphtheria exists 
at the same time in the same house, the question of transmission should 
have weight in making the diagnosis. Every case of membranous conjunc- 
tivitis requires a careful inspection of the fauces. If croupous laryngitis is 
present-, then a greater probability of diphtheria is warranted. 

Symptoms. — A grayish-yellow patch can be seen on the conjunctiva. 
The lids are very tender and swollen. They feel hard and thick on palpa- 
tion, and cannot be everted. Ulceration or sphacelation of the cornea 
usually follows. The same systemic disturbances may be noted as are found 
in diphtheria affecting the throat. There is usually fever, glandular en- 
largement, loss of appetite, general prostration, and cardiac disturbances, 
as has been described in the chapter on "Diphtheria." 

Prognosis. — A very guarded prognosis is necessary, as the outcome of 
the case depends upon the care bestowed and the time when the case was 
first seen. If the disease has been established a long time, a greater de- 
structive tendency must be presumed than if the case was seen when it first 
originated. 

Treatment. — First isolate. The communicable nature of this disease 
must be remembered. The family and friends should be warned of the 
danger. 

Local Treatment. — If the eyes are thick and swollen, an ice-bag or 
ice-cold pledgets of cotton soaked in bichloride. 1 to 2000, should be ap- 
plied. They should be renewed every five to ten minutes night and day, 
to produce a good result. In other cases warm, moist applications will 
alleviate pain and also reduce inflammation. 

Specific Treatment. — Diphtheria is diphtheria whether it is in the eye 
or in the throat, hence an injection of 5000 units of antitoxin should be 
given regardless of the age of the child. The same internal treatment 
which is described in the chapter on "Diphtheria" is recommended if we 
desire successful results in these cases. 

Granular Ophthalmia (Trachoma). 

The characteristic feature lies in the development on the palpebral 
conjunctiva of the so-called "sago grains." 

Granular lids must be carefully considered owing to their disastrous 
tendency. 



ORAM LAK OPHTHALMIA. 



865 



The following table, slightly modified from Stephenson ("Epidemic 
Ophthalmia," L895) gives the differential diagnosis between t'olliculosis 
of the conjunctiva and trachoma : — 

Table No. lit-"). 



FALSE OR FOLLICULAR GRANULATION. 

1. Oval or roundish transparent 
bodies the diameter of which never ex- 
ceeds from 1 millimeter to 1 '/ 2 milli- 
meters. Of a faint yellowish hue, ar- 
ranged in rows parallel to the lid border, 
and discrete. Most marked in inferior 
retrotarsal fold. 



2. Little or no change in the structure 
of the conjunctiva. 

3. Papillary hypertrophy of upper lid 
slight. 

4. Tarsus never implicated. 

5. Disappear spontaneously generally 
and leave no scar. 



TRACHOMA. 

1. Round, opaque, ill-defined bodies, of 
grayish- white color and extreme friabil- 
ity. Firmly and deeply embedded in the 
conjunctiva, their diameter not in- 
frequently reaches 2 millimeters or more. 
Tendency to become confluent and form 
masses or areas of trachomatous ma- 
terial. Most numerous and larger in 
upper retrotarsal fold. 

2. Structural changes always present. 



3. Marked hypertrophied papillae of 
upper lid generally present. 

4. Tarsus often involved. 

5. Spontaneous cure may occur, but 
only by cicatrization, which may be 
slight or extensive according to the 
amount of tissue involved. 



6. Xo ptosis. 

7. Xo pannus. 



8. Xo trichiasis, entropion, or cica- 
tricial contraction of the cul-de-sac. 

9. Most frequent in persons under 20 
vears. 



6. Ptosis nearly always present in 
some degree. 

7. Keratitis in the form of pannus or 
ulcer in about 25 per cent, of the cases. 

8. Frequently leads to trichiasis, en- 
tropion, or shrinking of the cul-de-sac. 

0. May occur at any age. 



10. Xon-contagious. 



10. Conditionally contagious. 



This disease may frequently assume an epidemic nature. Dur- 
ing the last two years hundreds of cases have suddenly appeared in our 
city. The ease with which all infectious diseases spread in the congested 
portions of our city applies to trachoma. For this reason school-children 
and inmates of institutions and hospitals should have the eyes carefully 
inspected on admission to exclude trachoma. In our country the native 
American Indian suffers from this disease, so do the Irish, Polish, Italians, 



866 



DISEASES OF THE EYE. 



and the Teutonic races. It is therefore quite probable that this disease is 
spread more or less among all races. One race is exempt, namely, the 
negro. 

Treatment. — Of all methods, expression is the method generally nsed. 
The morbid tissue is thereby dislodged and removed. Actual cauterization, 
galvano-cautery, or the solid nitrate of silver stick is mentioned by some, 
but should be used onlv by those familiar with the eye. The advice that I 
give in my office to patients suffering with trachoma, is to recommend them 
to an eye specialist. 




Fig. 287. — Trachoma, Showing Round, Opaque Bodies in Upper and 
Lower Lids. *'Sago grain" type. From a photograph — frequent type seen 
in children. (Original.) 



Blepharitis. 

This disease is characterized by a sub-acute or chronic inflammation 
along the margin of the lids. 

Two classes of cases might be noted. First, those in which slight 
crusts appear on the edges which, when cleared off. show no loss of sub- 
stance; simply reddened margin. This would include the cases of mar- 
ginal eczema, so called. Second, those cases which, when cleared of crusts, 
show ulceration. 

The first chss of cases seek treatment for cosmetic results. There is 
no pain, only a slight discomfort exists. These cases are all aggravated 
by exposure to dust. wind, heat, or long spells of work. 

The second class of cases is more serious. At first they present a dusky 
margin and gluing together of eyelashes, due to excessive secretion, which 



HORDEOLUM. 



807 



gradually progresses. Beneath the crusts ulcers form. Excoriations and 
pustules about the hair follicles interfere with the growth, so thai the 
lashes fall out or become stunted. The vascularity continues, increasing the 
thickness of the lids with new connective tissue. The gradual contraction 
of this new scar tissue leads to eversion of the lids with resulting epiphora. 
or overflow of tears, presenting a disagreeable, raw-looking surface. 

Treatment. — Generally speaking, the treatment consists of removing 
the crusts or scabs by any warm alkaline lotion, such as bicarbonate of soda, 
or biborate of soda, 10 to "20 grains; aqua?, 1 ounce. Massage of the lids 
with red or yellow oxide or white precipitate, 2 to 8 grains ; vaseline, 1 ounce, 
should follow. 

A mild ointment should 
be used — a strong one in- 
creases the irritation. All re- 
fractive errors must be cor- 
rected. Epilation of the 
lashes sometimes promotes a 
cure when commenced in the 
early stages of the disease.. 
The general condition of the 
patient must be looked after, 
and iron, arsenic, codliver- 
oil, or similar tonics and hy- 
gienic treatment as indicated 
should be prescribed. 

Hordeolum, or Stye. 

This disease is character- 
ized by an inflammation of 
the connective tissue about a 
hair follicle along the lid 
margin. A hard, circum- 
scribed, inflammatory nodule forms, which may suppurate. Occasionally, it 
remains as a hard lump, and still in other cases the lid becomes swollen and 
©edematous. A close examination, however, will show the inflammatory spot, 
which as soon as it appears yellowish should be incised and the pus evacu- 
ated. 

Treatment. — The general treatment consists in hot applications to 
favor resolution. To prevent successive crops, the massaging of the lids 
with an ointment of hydrarg. ox. flav., 1 / 2 to 2 grains; vaseline, 2 drachms, 
has an excellent effect. The infection from the pus may be prevented by 
the use of argyrol in a 5 per cent, solution, one drop two or three times 
daily. 




Fig. 288.— Method of Everting Eyelid. 
(After Davis and Douglass.) 



80g DISEASES OF THE EYE. 

These successive styes show some disease of the lid margin, as blepha- 
ritis, some derangement of the general system, or eye-strain, especially in 
hypermetropia. 

Phlyctenular Conjunctivitis. 

This affection is one of childhood and is seen in malnutrition after 
the acute exanthemata ; also in marasmic or scrofulous children. 

Small elevated spots, papules, or pustules the size of a mustard seed 
are .found in this condition. When the epithelial covering is shed they 
become superficial ulcers. They are either single or multiple, and appear 
as pinkish, yellowish, or grayish spots. There is very often a great dread of 
light — photophobia — which leads to spasms of the lids — blepharospasm. 
There are also at times pain, burning sensation, and lachrymation. 

Treatment. — Local treatment consists of bathing with a saturated solu- 
tion of boric acid. If any excoriation exists at outer canthus, touching it 
with nitrate of silver generally effects a cure. 

If the symptoms show that the condition is subacute or chronic then 
stimulating applications are required, as : — 

Ifc Hydrarg. ox flav 4 to 8 grains 

Vaseline 1 ounce 

M. and apply three times a day. 

I have had excellent results by touching the affected parts lightly with 
a solid stick of alum or copper. 

If there is much corneal involvement : — 

IJ Atropin sulph V 2 grain 

Aq. dest 2 drachms 

Sig. : One drop in the eye once or twice daily may have to be used. 

For the blepharospasm, a force I opening of the lids, an occasional drop 
of a 2 per cent, solution of cocaine, or a sudden plunging of the head in 
cold water will relieve the condition. 

General Treatment. — This consists in the hygienic care of the child 
and tonic treatment. The eyes should be kept clean and open, dark glasses 
should be worn if necessary. No dark room, bandages, or eye shields should 
be allowed. The bowels should be regulated. The diet should be looked 
into. All sweets interdicted, meat given occasionally, and milk foods or- 
dered. Give plenty of fresh air, outdoor exercise, and bathing. Tonics, 
such as codliver-oil, syr. ferri iodide, strychnine, etc., should be given. 



CHAPTER III. 
DISEASES OF THE SKIN. 

Eczema. 

This eruptive disease is very frequently seen in infants as well as in 
older children. 

Etiology. — Irritation, be it an irritant soap or an irritant discharge 
can give rise to eczema. Eczema is frequently an external manifestation 
of toxic conditions. The frequency with which eczema is seen in children 
with dyspeptic conditions certainly invites consideration. Children having 
rickets are frequent sufferers with eczema. Some authors believe that 
pathogenic bacteria can enter the shin and set up eczema. AYhile this ap- 
pears plausible, it remains to be proven. It is found associated with de- 
ficient elimination from the skin in the unclean, in dyspeptic conditions 
when the stomach and bowels are not properly functionating, and also 
when the kidneys do not properly act. I have frequently seen children 
with a facial eczema which appeared when oatmeal was given and disap- 
peared when the same was stopped. Eczema may be clue to reflex irrita- 
tion. Holt says that cases which accompany dentition and those due to 
genital irritation can be called reflex. 

This disease can be either localized (regional), as when it is confined 
to the face or between the thighs, or it can be general or universal. 

Symptoms. — There is always an intense itching or burning with the 
appearance of the eczema. On the cheeks it usually begins with "small 
red papules, later these coalesce and there is a moist red surface exuding 
serum or sero-pus.'* Children scratch and thus usually produce bloody 
streaks. Hie crusts have a yellowish-brown appearance. There is a red- 
ness, thickening, and always scaliness of the skin. The glands in the im- 
mediate neighborhood are usually swollen ; they rarely lead to suppuration. 

Eczema frequently spreads from the face to the forehead and the neck, 
and I have seen it involve the whole head. 

Infant O. S., seven months old, was nursed about six weeks at his mother's 
breast. He was then fed on top milk and barley water. As this disagreed he was 
given barley water. He then had dyspeptic, greenish stools, and the feeding was 
changed to milk and rice water, which seemed to agree quite well. He gained steadily 
one-half pound every week for the next three months. He was at the seashore all 
summer and had no evidence of summer complaint. When seven months old he 
was slightly constipated and with it had dyspeptic fermentation. His appetite was 
poor. It was necessary to stimulate the bowels to produce proper evacuations. 

(869) 



870 DISEASES OF THE SKIN. 

Teething appeared at about the eighth month. At the same time the child had a 
severe attack of influenza of the gastric type, with high fever, anorexia, and gastro- 
intestinal atony. At this time a scaly and papular eczema appeared on one cheek 
and rapidly spread to both cheeks. With the application of a bland ointment con- 
sisting of zinc oxide and vaseline it disappeared. One week later I again saw tliis 
child with a relapse of high fever and dyspeptic symptoms, and a severe eczema 
covering an area larger than before. It was very red and angry looking and weep- 
ing in character. A gauze mask saturated with calamine and zinc lotion (3 per cent.) 
produced a marked improvement, besides relieving the itching. Internally I gave rhu- 
barb and soda tablets in addition to cutting down the quantity of milk one-half 
of the previous strength. After three weeks of this form of treatment I was able to 
return to the former full milk feeding and the eczema did not return. 

The following prescriptions are valuable: — 

CALAMINE LOTION. 

I£ Pulv. calamini , 2 parts 

Pulv. zinci ox 2 parts 

Glycerini 1 part 

Aq. rosae 30 parts 

unna's soft zinc paste. 
H 01. lini, 
Aq. calcis, 
Zinci ox., 
Cretse of each, equal parts 

Treatment. — Bland unirritating applications, snch as rice powder, 
zinc oxide, stearate of zinc, talcum, or cornstarch, are very cooling, and 
seem to act by absorbing the heat and moisture if any be present. 

Bathing in Eczema. — I have frequently found an apparently cured case 
of eczema break out anew with a red blush and eczematous patches after 
one ordinary cleansing bath was given. In the acute stages water should 
he omitted. Applications of a 5 or 10 per cent, calamine and zinc salve 
or lotion, as described in the clinical case above given, are very beneficial. 
Soap should never be used. When hard crusts cover the surface of the 
skin and cannot be softened by the ordinary applicat:'on of salves, the fol- 
lowing treatment should be instituted: A bland bath consisting of one 
pound of oatmeal in a cheese-cloth bag, should be thoroughly soaked in hot 
water for at least one-half hour, and enough water added to bathe the 
eczematous parts. After thorough soaking in this oatmeal bath the cala- 
mine and zinc or a 2 per cent, boric acid and vaseline ointment should 
be applied. One bath only should he given. The salve should be applied 
three times a day for at least one week. Irritating ointments, or those 
containing tar, should be avoided in the acute condition. 

Eczema Eubbum. 
The eczematous blush affecting the face may be mistaken for erysip- 
elas. Erysipelas usually occupies a smaller area, generally on the bridge of 



URTICARIA. 871 

the nose. High fever usually accompanies erysipelas; this will easily dif- 
ferentiate the condition. The treatment is the same as that outlined in 
the article on " Eczema. " 

SALICYLIC-SULPHUR PASTE. 

ffc Ac. salicyl 1 part 

fSulph. depur 5 parts 

Petrolatum 25 parts 

Zinci oxid 10 parts 

Amylum 10 parts 

ICHTHYOL OINTMENT. 

Amnion, sulph-ichthyolat 5 parts 

Ap. dest 5 parts 

Adeps benzoat 15 parts 

Adeps lanse 25 parts 

Eczema Intertrigo. 

In fat children where two opposing surfaces of skin are in contact, 
such as between the thighs or toes or in the armpits, a red form of inflam- 
mation frequently ensues. It is sometimes accompanied by a thin, foul- 
smelling discharge, which may be serous, but very rarely is purulent. This 
condition is more apt to be noticed in the unclean. 

Treatment. — Eemove the cause by separating the parts. Sprinkle 
freely with talcum, zinc oxide, lycopodium, Fuller's earth, or any good 
infant's powder. In severe cases separate the parts by placing a sterile pad 
of cheese-cloth on both skies of which zinc salve is smeared. All warm 
clothing should be avoided. When severe excoriation results from dis- 
charges and is not checked by the application of bland salves, then cool 
lead and opium wash applied for a day or more is soothing and will reduce 
the inflammation. 

Erythema. 
Local irritation such as might be caused by a mustard plaster or the 
friction of a dress, producing a "chafe," or irritating secretions, such as 
a purulent ophthalmia or acrid discharge from the nose, produces this ery- 
thema. It is frequently seen in infants on the buttocks from lack of clean- 
liness. When seen on the buttocks it may be mistaken for syphilis. Ery- 
thema is easily differentiated from syphilis by the absence of snuffling of 
the nose, of the ham-colored eruption, and of the inelastic cracked appear- 
ance of the soles and palms. 

Urticaria (Htyes: Nettle Rash). 

This inflammatory condition of the skin appears very suddenly. No 
special portion of the body is exempt ; thus, it may occur on the face, 



872 DISEASES OF THE SKIN. 

abdomen, or extremities. It consists of irregular shaped blotches called 
wheals. When these spots disappear they leave no trace behind. There 
are several varieties of urticaria. 

Urticaria annularis occurs in rings. 

Urticaria figumta occurs in spirals. 

Urticaria vesiculosa has vesicles on the summit of the wheal. 

Urticaria bullosa is a bullous development on summit of wheal. 

Urticaria papulosa is a wheal combined with a papule. 

Urticaria tuberosa are giant wheals. 

Urticaria hcemorrhagica is a combination of urticaria with purpura. 

Urticaria pigmentosa is a pigmentation following the wheals. 

The form most frequently met with in children is likely due to (a) 
ptomaine poisoning; (b) the result of some toxin in the system. 

Causes. — Shell-fish, strawberries, and frequently cereals seem to be the 
cause of urticaria in some children. There is usually some gastric or gastro- 
intestinal disturbance at the time of the appearance of this rash. There 
seems to be a peculiar idiosyncrasy in some children to quinine and to 
other drugs which will bring out an attack of urticaria. A great many 
children have severe urticaria after an injection ol' antitoxin. (Eead 
article on "Antitoxin Bashes.'') Insect bites will sometimes cause this 
condition. 

Symptoms. — There is severe itching, and scratching will frequently 
develop a new rash. Fever sometimes accompanies this condition. Urti- 
caria once seen is very easily recognized and is not hard to differentiate. 

The prognosis is usually good. We must remember that children prone 
to idiosyncrasies will have urticaria quite frequently, thus it will depend 
on the diet as to whether or no the rash remains away. 

Treatment. — The first thing to do is to cleanse the gastro-intestinal 
tract. A saline or citrate of magnesia will always do good. Xext in im- 
portance is the regulation of the diet. If a cause is found, remove the 
same. 

Locally. — The severe itching can best be allayed by making a paste 
of bicarbonate of soda and cold water. Bub this paste into the hives. A 
cool tub bath, containing several ounces of bicarbonate of soda, will fre- 
quently relieve the itching. Menthol. 5 to 10 grains to 1 ounce of water, 
applied by means of a cameFs-hair brush, is advised by some. Evaporat- 
ing lotions, such as lead and opium wash or a weak solution of vinegar and 
water, or carbolated water, are recommended externally. 

Large quantities of water should be given for thirst. It will also aid 
in eliminating toxins through the kidneys. 



PSORIASIS. 873 

Herpes Zostek (Shingles). 

"This is an acute inflammation consisting of a group of vesicles. It is 
mostly seen over a surface of skin corresponding to a definite nerve tract. 
It is accompanied by neuralgic pain." 

Symptoms. — As a rule there is a broad band of vesicles corresponding 
to the affected area, usually following a nerve tract along the limbs or along 
the borders of the ribs. It develops very rapidly and frequently resembles 
an erythema. The crop of vesicles is frequently so thick that they almost 
touch one another. 

Prognosis. — As this is a self -limited disease the prognosis is good. 
although neuralgic pains may persist for some time after the disappearance 
of the eruption. 

Treatment. — Avoid irritant salves and use cooling dusting powders, 
such as bismuth, cornstarch, wheat flour, or powdered zinc oxide. The 
affected part should be covered with linen or gauze, not flannel or wool. To 
allay intense itching or inflammation use calamine and zinc lotion (see 
chapter on "Eczema"). 

Chloasma (Tixea Versicolor: Liver Spots). 

This is a very mild form of eruption in which brown patches of skin 
are seen. It is caused by the invasion of a fungus. 

Treatment. — The application of white precipitate ointment or 1 per 
cent, bichloride in alcohol has served me very well in removing the same. 

Psoriasis. 

This is a chronic inflammatory disease affecting the extensor sur- 
faces. It consists of a red scaly patch in which white silvery scales abound. 

Etiology. — There is no specific factor, as it is found in both the rich 
and poor, although it frequently follows malnutrition of the body such 
as we see after the acute infectious diseases. This condition also fre- 
quently affects children of gouty parentage. 

Symptoms. — The extensor surfaces are usually affected, hence the dis- 
ease will be found on the extensor sides of the arms and legs. The sym- 
metrical arrangement of this eruption on both sides of the body is a char- 
acteristic condition. 

Prognosis.- — This should always be cautiously given. As the disease 
has a chronic tendency it may remain for years unless actively treated. 

Treatment. — Locally : — 

Jfc Resorcin 1 grain 

Vaseline 1 ounce 



874 DISEASES OF THE SKIN. 

Great care should be used in prescribing pure alcohol or tar. Such 
strong remedies should be avoided and a dermatologist should be consulted 
before advising heroic treatment. The following ointment has acted very 
well in these conditions : — 

fy Acidi carbolici 5 grains 

Bism. subnitr 7 2 drachm 

Unguent, hydrarg. amnion 1-2 drachms 

Ung. aquae rosae ad 1 ounce 

M. To be thoroughly rubbed into the affected patches, either alone or after 
washing with: — 

R Acidi salicylici 1 scruple to 1 drachm 

Spts. vini rectif 1 ounce 

Glycerini 4 drachms 

Aquae rosae ad 4 ounces 

(Bulkley) 

Systemic Treatment. — Xo one must expect to cure this disease unless 
the emunctories are properly looked after. We must keep the bowels loose, 
the kidneys active, and give a vegetable, fruit, and cereal diet. The dairy 
products should be permitted, but meat must be excluded. 

Eestorative treatment such as codliver-oil, iron, and arsenic should be 
given liberally. In this disease arsenic proves itself of great value. Ar- 
senic need not be feared and can be given to children in very large doses. 
Fowler's solution, in 3 to 10-drop doses three times a day, is usually suffi- 
cient. 

Impetigo. 

This infectious and contagious disease is characterized by an eruption 
which may appear on any part of the body. It is most frequently seen on 
the exposed parts, usually on the face and hands. It is most probably 
caused by the presence of the staphylococcus or streptococcus. 

Symptoms. — There may or may not be fever at the onset of the erup- 
tion. The eruption usually commences on the face and hands. It is easily 
communicated from the sick to the well, as the following case will illus- 
trate : — 

F. R., 2 years old, was sent to me by Dr. W. H. The child had been in 
good health when one day the mother noticed a pustular eruption on the face, 
chiefly on the cheeks. Later it spread to the scalp and hands. It was associated 
with scabies and contracted by scratching. The infection spread to a second child 
and I was informed that some children playing with the patient contracted the 
disease. The treatment consisted in clipping the hair and saturating the parts with 

Ifc Ichthyol 1 drachm 

Vaseline 1 ounce 

This was applied three times a day with good result. Attention was directed to the 
condition of the stomach and bowels. AH*t. rhei et sodae. a teaspoonful was given 
three times a da v. 



MILIARIA PAPULOSA. 875 

The disease can easily be carried by clothing infected with the dis- 
charges from the crusts. In one case 1 recall, the child contracted im- 
petigo by wearing the stockings of her older sister who was sick with the 
disease. 

Treatment. — A general outline of the treatment has already been 
described in the clinical case given above. 

A tub-bath consisting of kali sulphur (one ounce), dissolved in a 
porcelain or wooden tub full of water. The temperature of this bath should 
be about 100° F., and the duration of the bath about fifteen minutes. This 
bath should be repeated every night, before retiring, for one week. Follow 
the same with the ichthyol ointment well rubbed in, as above described. 

Pediculosis. 

Among the poor or unclean we frequently see this condition. It is 
caused by the invasion of a parasite, the pediculus capitis. There is usually 
an eczematous condition and the adjacent glands are swollen. The habitat 
of the pediculus is in the hair, but it causes eczematous patches by irrita- 
tion. 

Treatment. — First remove the hair if it is at all possible; if not. 
saturate the hair with petroleum. This should be left on about five or six 
hours, after which the scalp and hair should be drenched with warm soapy 
water. The same treatment will be necessary every few days until a cure 
is effected. 

Tincture of larkspur (tr. delphin.) is another valuable preparation 
when petroleum is objectionable. The hair and scalp should be thoroughly 
saturated with larkspur morning and evening and then thoroughly washed. 

Miliakia Papulosa (Lichen Tropicus: Prickly Heat). 

This variety of skin disease is frequently seen in summer. It consists 
of bright red papules on the summits of which there are very tiny vesicles, 
at times pustules may also be seen. The eruption is usually confined to 
those parts which are w r armly clad, so that the abdomen, chest, and the 
extremities are most frequently covered. Eczema frequently follows this 
condition, and if severe scratching takes place, local infection ending in 
furunculosis may occur. The other parts of the body which do not have 
the eruption usually show extensive perspiration. This eruption comes 
and goes very quickly. It is frequently mistaken for scarlet fever. The 
absence of fever, the appearance of the tongue and throat, and the absence 
of the prodromal symptoms will easily differentiate this condition. 

Treatment. — Ehubarb and soda or a dose of calomel at the beginning. 
If the kidneys are inactive, then 10 to 20 drops of sweet spirits of niter 
should be given, and repeated two or three times a day. For the intense 



876 DISEASES OF THE SKIM. 

itching the application of a paste consisting of bicarbonate of soda and 
water, will stop the itching. The body should be made comfortable by 
removing all warm clothing. A tepid alkaline bath, temperature ^0° P. — 
a bath to which several ounces of bicarbonate of soda has been added — 
is very grateful and will give quick relief. After the bath dry the body 
thoroughly and dust cornstarch or wheat flour with talcum or zinc oxide. 
and let the child sleep with as little clothing on as possible. If im- 
provement does not follow within twenty-four hours, then the application 
of the following salve will relieve itching and reduce the inflammation: — 

R, Zinc oxide 1 drachm 

Calamine 1 drachm 

Cold cream 1 ounce 



M. Apply three times a di 



IV 



MlLIARIA El'BEA (STROPHULUS INFANTUM: EED Gull). 

This rash is the result of an irritation due to perspiration. It con- 
eonsists of red papules, sometimes having tiny vesicles. It is usually seen 
on the cheeks of an infant and always upon the side on which the infant 
sleeps. 

The treatment is the same as that given in the chapter on "Miliaria 
Papulosa. '' 

SCDAMINA. 

Sudamina are small pearly bodies occurring during fever or exhausting 
diseases. They are usually seen over the sweat ducts. They are easily 
absorbed and fresh crops take the place of these tiny vesicles. 

Lentigo ( Freckles) . 

This is a very common affection of the skin. It is usually seen in 
children over 5 years of age. and most especially in those having blonde 
ot red hair. The skin is certainly more sensitive to sunlight in such case-, 
and successive crops of freckles frequently appear after exposure to the 
light. 

The treatment consists in protecting the skin against exposure to the 
light. The freckles can be removed by a mild form of counter-irritation 
such as the application of a 1 per cent, solution of bichloride of mercury. 
Apply on cotton to the affected area for three or four successive hours. This 
form of counter-irritation destroys the skin, causing it to desquamate. The 
new epidermis which appears is free from this pigment. 

Seborrhcea. 

This is a very common condition of thick, dry. crusty formation which 
occurs on the head of infants. Tt most frequently involves that region 



FURUNCLE. 



87 



surrounding the anterior fontanel. There are two varieties: (a) sebor- 
rhea oleosa; (b) seborrhcea sicca. Sonic authors state that if fhe vernix 
caseosa in the new-born is allowed to continue it passes into a seborrhcea 
and may eventually become an eczema. When carefully examined, sebor- 
rhcea will be found to consist of epithelial cells, fat, and chiefly dirt. There 
are no inflammatory symptoms. When the scales are removed the skin is 
usuallv found normal. 



Treatment.- 



-The following is recommended 



Ifc Salicylic acid 15 grains 

Vaseline 1 ounce 

M. Hub the scalp thoroughly several times a day and leave on over night. 
Wash scalp with soap and warm water the following morning. If necessary repeat 
several evenings and wash in the morning as above directed. Sulphur soap is useful 
in this condition. The officinal ointment of sulphur can be rubbed into the scalp if 
this condition recurs. 



Furuncle (Boil). 

This inflammatory condition occurs around a hair follicle or a gland 
of the skin. It is most likely caused by scratching, during which process 
there is an infection of the follicle with pyogenic bacteria such as staphy- 
lococcus pyogenes aureus. Frequently we see boils scattered through the 
scalp in large crops. At other times they occur singly. A boil begins 
as a small red spot in the true skin, very tender, and growing larger and 
larger. On palpation the center is soft and there is a tendency to sup- 
puration. After suppuration has taken place and the boil emptied the 
swelling subsides. 

Differential Diagnosis. — A furuncle has but one point of suppuration, 
whereas the carbuncle has many. A furuncle is usually a small swelling. 
A carbuncle very large, frequently several inches in diameter. 

Diagnosis. — The diagnosis is usually very simple. This condition is 
usually met with in rickets. It especially affects those children having a 
tendency to head sweating. 

The prognosis is usually very good. 

Treatment. — Aseptic surgical details are demanded in each and every 
instance. The scalp should be shaved. The area of the skin involving the 
furuncle should be washed with carbolated soap and Avater, and subse- 
quently with water. A free incision should be made, the pus liberated, and 
the part dressed with sterile gauze. 

Iron, codliver-oil, and other restoratives are indicated. The value of 
nutritious food must not be overlooked. 



S78 DISEASES OF THE SKIN. 

Chronic Pemphigus. 1 

This frequently follows the acute condition. It resembles the acute 
disease in producing a succession of crops of bulla?. 

The prognosis depends on the condition of the child at the time when 
it was first attacked. If the infant is underfed and its vitality lowered 
thereby, then active restorative treatment should be instituted or the case 
will be lost. 

Treatment. — The blebs should not be ruptured. They should be al- 
lowed to dry. The surface of the skin in the immediate neighborhood 
should be protected by a bland non-irritating ointment such as zinc salve 
or diachylon salve. 

Sprinkling powder of zinc oxide, borated talcum, or cornstarch should 
be used. If the bullae rupture, the serum should be absorbed with a little 
cotton and the neighboring parts protected from the excoriating effect of 
the contents of the ruptured bulla?. Careful attention must be given to 
the stomach and bowels. If necessary, a mild laxative should be given. 
The diet should be regulated both as to quantity and quality. 

Xjeyus. 

There are two kinds of naevus usually seen: (a) pigmentary, (&) vas- 
cular. Pigmentary occurs as small, rounded stains, which are either yel- 
lowish or dark brown. The cutis is raised, thickened, and frequently sur- 
rounded with a tuft of hair. They are most commonly seen on the face, 
neck, and hands. 

Vascular nosvus may be level with the skin or appear as tumors which 
project beyond it. The former is due to an excessive development of the 
capillaries of the skin. Commonly met with it is of a purplish hue, 
although it may be brick red, claret red, or a livid blue color. They are 
most commonly seen on the face and neck. 

Treatment. — Blistering or caustics are recommended for the cure of 
this condition. I have frequently seen marked benefit from linear scari- 
fication by the Paquelin cautery. A radical operation should be considered 
if this milder form of treatment is unsuccessful. 

Tixea Toxsuraxs (Kixgworm). 

This disease is caused by the trichophyton tonsurans. When located 
on the scalp it is called herpes tonsurans; when on other parts of the 
body it is known as herpes circinatus. 

Microscopical Appearance. — Squire says: "Under the microscope the 
stump of the hair appears ragged on either of its ends. Instead of break- 



1 See article on "Pemphigus Neonatorum." 



TINEA TONSURANS. 879 

ing with a clean fracture, like healthy hair, the broken ends are digitated. 

The structure of the hair is greatly altered; its fibers are separated longi- 
tudinally, and the intervals filled with the spores of the trichophyton. On 
the surface of the hair are clusters of the same spores. The magnified 
piece of hair looks something like a bundle of faggots, with a number of 
berries sticking in clusters to its sides and ends, and stuffed here and there 
into its interstices. The spores of the trichophyton are rounded, have a 
well-defined outline, and measure about V5000 ^ ncn across. In the earlier 
stages of the disease, when the hair has not yet become so brittle as to 
make it impossible to extract the root, it can be ascertained that the knob 
of the hair, as well as its root-sheath, is invaded by the spores of the tri- 
chophyton.'' 

The disease commences with more or less itching and redness of some 
parts of the scalp ; sometimes there is swelling. The hair growing on these 
patches loses its polish, and becomes dull. It is also brittle and easily breaks 
oil near the root. This breaking off of the affeeted hairs gives the patch 
the appearance of having been lately shaved. There is a furfuraceous des- 
quamation plainly seen on the scalp. The hair follicles become erect and 
the patch assumes a goose skin appearance. The margin of the patch is 
abruptly defined. There are usually several patches seen on different por- 
tions of the scalp. If we attempt to pull out the hair stumps by means of 
a tweezer we will note that only a portion of it comes away, leaving the hair 
root in the skin. 

Treatment. — This consists in first cutting the hair as short as possible. 
Near the patch and around it a strong antiseptic soap such as a bichloride 
soap should be used. Absolute isolation should be enforced and children 
affected with the disease should wear oil-silk caps. 

In an epidemic of ringworm in the Xew York Infant Asylum, the 
following combination of bichloride and kerosene proved extremely satis- 
factory : 10 grains of the bichloride were dissolved in alcohol, and to this 
were added 2 1 / 2 ounces each of olive-oil and kerosene. This was applied 
every day, being thoroughly rubbed into the diseased patches, and the 
whole scalp saturated with it. Considerable irritation usually resulted, 
and every few days the parasiticide was omitted and some simple emol- 
lient applied until the irritation had in a measure subsided. In some of 
the cases, the tincture of iodine was alternated with the bichloride and 
kerosene. Twenty-six cases were treated after this plan and all cured, 
the average duration of the treatment being eight and a half weeks. 1 

My own experience has been very successful with this method. Some 
authors advise an ointment composed of precipitated sulphur or citrine oint- 
ment. Another remedy advocated in this condition is washing the head 



x See C. G. Kerlev's report in Xew York Medical Journal, October 10, 1891. 



380 DISEASES OF THE SKIN. 

daily with a strong antiseptic soap and then applying nitric oxide of mer- 
cury ointment. 

The following method is also of value : — 

Eemove the superficial scales with the tincture of green soap, or by 
the use, for a day or two, of the pure green soap spread upon a piece of 
lint. Corrosive sublimate in 1 per cent, solution may be applied once a 
day, or the tincture of iodine, or carbolic acid in glycerine, 1 to 16, or the 
white precipitate ointment may be employed. I prefer the chrysarobin 
collodion painted over the patch every day or every other day. Kaposi's 
naphthol ointment is recommended by Lassar. Tar or sulphur ointments 
or Lassar's paste may be employed in obstinate cases. 

Morris's thymol-chloroform oil is also beneficial. 

morris's thymol-chloroform oil. 

Ifc Thymol 1 part 

Chloroform 4 parts 

01. olivse 12 parts 

Or:— 

SUBLIMATE SPIRIT. 

Ifc Hydrarg. chlor. corr 1 part 

Spts. villi rect 500 parts 

Or:— 

TANNIN-SULPHUR PASTE. 

R Acid, tannic 5 parts 

Lac. sulph 10 parts 

Petrolati 50 parts 

Zinci oxidi 17.5 parts 

Amyli 17.5 parts 

Or:— 

CHRYSAROBIN COLLODION. 

B Chrysarobini 1 part 

Collodion flexible 10 parts 

Verruca (Warts). 

These small tumors of the skin are frequently met with in children. 
They may resemble a bunch of carrots (verruca digitata) or they may 
resemble a cauliflower. In size they vary from one-sixteenth to one- 
eighth of an inch in height. They frequently are seen on the face, neck, and 
hands. They produce no discomfort and are not serious. 

Treatment. — Freeze the parts with ethyl chloride or ether. Pick the 
wart with a sharp curette. Another painless method consists in cauterizing 
first with pure carbolic acid, on top of which fuming nitric acid is applied. 
In using the latter caustic method the surrounding parts should be pro- 
tected with vaseline. 



GANGRENE. 881 

Burns (Combustio). 

We frequently see burns of various degrees in children. 

Causes. — They are usually caused by hot water, steam, acids, or alka- 
lies. 

Symptoms. — An intensely inflamed area surrounding a blistered sur- 
face is usually found. Pain and sometimes shock is noted. In some eases 
fever and a rapid increase in the pulse are noted. Violent reaction such 
as convulsions frequently occur in weak and rachitic children if a severe 
burn has taken place. 

Prognosis. — This depends upon the amount of surface involved and 
on the condition of the child at the time of the accident. Some children 
survive extensive burns with good care. As a rule a cautious prognosis 
should be given, owing to the risk of infection and danger of shock. 

Treatment. — Strict asepsis should govern the opening of all blisters. 
Cornstarch, wheat flour, europhen, or dermatol may bi' used locally. In 
addition thereto linseed-oil and lime water or calamine and zinc- lotion 
(see chapter on *'Eczema v ) is very valuable. Nutrition forms the most 
important part of the restorative treatment. 

Gaxgrexe (Superficial Gaxgrexe). 

This condition affecting the skin or extending to the deeper structures 
is characterized by a bluish black discoloration resembling a deep form of 
cyanosis. 

Causes. — It is a destructive condition following the acute infectious 
diseases, especially scarlet fever or measles. Traumatism or pressure inter- 
fering with the circulation of the blood or robbing the extremity of its 
nutrition may result in a destructive gangrene. The following case of 
traumatic gangrene occurred in my practice; it was a traumatic gangrene 
due to interference with the circulation : — 

Baby A., ten months old, breast- and bottle-fed. was referred to me by Dr. A. 
Meyer. I found a temperature of 105° F., pulse 180. respiration 60. There was com- 
plete consolidation of one lobe of the left side. Bronchial breathing was plainly 
heard and there was dullness on percussion. 

The diagnosis of lobar pneumonia was made. With the aid of cold packs and 
small doses of strychnine, the child's condition improved. As I left the city the case 
was treated by Dr. Khodoff, who gave me the following memoranda: — • 

"The nurse administered a high rectal enema by suspending the child with a 
towel around the thighs. The circulation was thereby interfered with. I believe the 
thrombosis which appeared at about the saphenous opening was of traumatic origin 
due to this interference of the circulation. The course of the gangrene was as 
follows: A bluish purple spot about the size of a ten-cent piece appeared at the 
saphenous opening. The child previous to this showed indications of pain. It was 
fretful, tossing about, and very restless. The gangrenous area increased on the 
following day. It was decided to wait for a line of demarcation as the child appeared 

50 



882 



DISEASES OF THE SKIN. 



to be in a state of collapse. On the third day after the first sign of gangrene 
appeared a rapid spreading took place upward along Poupart's ligament and con- 
tinued above and involved the umbilicus.'" 

When I again saw this case the gangrene involved the whole abdomen. The 
temperature was 102° F., the pulse very feeble, and the child in a state of collapse. 



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Fig. 289. — Case of Gangrene Following Lobar Pneumonia, Gangrene 
appeared on the tenth day of disease, due to a careless method of suspending 
the child by a towel around the thighs, which resulted in thrombosis, ending 
fatally. (Original.) 



It was necessary to stimulate and feed per rectum. The child did not respond to 
treatment and died in convulsions. 

Prognosis. — The prognosis is always bad, although surgery may be 
the means of amputating a gangrenous extremity and saving the rest of 
the body. 

Treatment. — There is no medicinal treatment worth trying. Surgical 
relief is our only hope. 



symmetrical gangrene. 883 

Symmetrical Gangrene (Raynaud's Disease). 

This is an obscure condition in which the gangrene is symmetrical. 

Etiology. — It is caused, no doubt, by the invasion of pathogenic bac- 
teria. Infectious diseases which devitalize the body are believed to pre- 
dispose to this condition. Injury and haemorrhages, such as epistaxis, have 
been forerunners of this condition. 

Symptoms. — When acute there is fever and enlargement of the spleen, 
hematuria, or hemoglobinuria. The affected part feels cold and appears 
bluish ; sometimes there are vesicles containing a sero-purulent fluid. This 
condition lasts from two to three weeks, although it may extend over many 
months. The disease ends in mummification and gradual decay of the 
affected parts. The toes, fingers, ears, or tip of the nose may be the seat 
of this affection. 

Prognosis. — A cautious prognosis should always be given. While 
records of cures exist, the diagnosis may always be questioned. 

Treatment. — General restorative treatment, concentrated foods, and 
hygiene should form the basis of treatment. The skill of the surgeon may 
eradicate the gangrenous parts. 

Scabies. 

This is a contagious disease caused by the female acarus burrowing into 
the skin. The characteristic features of this disease are that it is found 
between the fingers, in the axillae, on the flexor surfaces of the wrists, and 
also around the genitals. The eruption is either a papule, or a vesicle, some- 
times a pustule. There is an intense itching, and secondary infection 
results from scratching. Several children in the same family will usually 
be found so affected. 

The prognosis is always good providing thorough treatment is instituted. 

Treatment. — A hot bath to thoroughly soak the body and soften the 
epithelial scales, should be ordered. An inunction of 1 / 3 unguentum 
hydrarg., */ 3 vaseline should follow the bath. Sulphur soap may be used in 
addition to sulphur ointment if no benefit results from the foregoing- 
treatment. 



CHAPTER IV. 

ABNORMAL GROWTHS OCCASIONALLY MET WITH IN CHILDREN.' 

Abnormal growths are frequently seen in children. Some of these 
are malignant, while some are benign. We must not suppose that children 
do not have malignant disease. I have seen malignant sarcoma involving 
the whole of the left lung which crowded the heart into the right axillary 
space. 

Spindle-cell Sarcoma of the Thorax. 2 

Gustav L., a male child of about 8 years, was first seen by me in July, 1900. 
His mother gave the following history: — 

He was breast-fed about ten weeks and owing to a diminution in the quantity 
and quality of her milk, she was forced to wean the child. He then received sterilized 
milk. This food was given until the child was weaned from the bottle at about the 
end of his second year. 

When about six months of age, a large, glandular swelling commenced behind 
the right ear, which necessitated an incision. The attending physician said it was 
an abscess. At this same time, he had a severe attack of gastric fever. This required 
careful dietetic treatment. Cow's milk was continued in a more modified form. 

At age of 1 year the child was attacked with measles, accompanied by a. 
catarrhal bronchitis. Some cough remained and when the child was 2 years old he 
had a severe attack of pertussis. When the child recovered, he remained well until 
he was 3 V 2 years old, then he was infected with scarlet fever lasting two months. 
Thus the child passed his infancy with some gastric derangement, followed by measles, 
pertussis, and scarlet fever. He did not have croup or diphtheria. 

"Family History. — This is good. The parents of this patient are both living, and 
apparently strong and healthy ; they have two other boys, well and strong. There is 
no history of syphilis, rheumatism, gout, tuberculosis, epilepsy, nor anything of a 
malignant nature in the family, excepting this fact which is extremely noteworthy, 
that the grandfather had a sarcomatous tumor, which ended fatally. 

"Examination. — The patient was brought to me for the relief of a. number of 
tumors on the front of the thorax, which felt quite hard on palpation. At times a 
distinct sense of fluctuation could be made out, and when examined by an exploratory 
puncture, a few drops of thin, yellowish serum was obtained. These tumors have 
been very troublesome for the past few years. They have caused severe dyspnoea. 
The physician who treated this boy in Hamburg believed that the growths contained 



1 For complete list surgical works should be consulted. 

2 Read before the Section on Pediatrics, the New York Academy of Medicine, 
April 10, 1902. 

(884) 



SAKCOMA OF J HE THORAX. 



885 



pu& This statement was made to the family. The physician made an exploratory 
puncture and was rewarded by a few drops of thin, serous liquid, as in a puncture I 
made and obtained no pus. 

'"The >ize of the growth as seen externally is about 15 centimeters in length 
and about 6 to 7 centimeters in circumference. (See Fig. 200.) There is marked 
dullness on percussion extending over most of the left side. The tumor is surrounded 
by a network of veins, intensely engorged with blood. There is mediastinal pressure. 
As far a- can be -ten and palpated, the growth occupies that region of the thorax 
usually occupied by the heart. The growth varies in >ize from week to week. 

''The heart has been pushed to the right side and occupies the right axilla. The 
apex beat i> heard about two finger breadths below and to the right of the right 
nipple, i See figure 291.) 

''The pulse is 144. small, feeble, quite 
irregular and easily compressible. The 
respiration is irregular, of the Cheyne- 
Stokes type, and frequently sighing. It 
i> usually about 50-52 in a minute: the 
temperature is always above normal and 
varies from 100° F. in the rectum, morn- 
ing, to 101 -/ 5 ° in the evening. There is 
always a febrile tendency. 

''There is constant dyspnoea and also 
extreme cyanosis of the lips, fingers and 
toes. The child is very pale and in a 
very anaemic condition. There is extreme 
pallor of the conjunctival membrane, the 
gums, and the mucous membrane of the 
lips.'' 

Owing to the extreme amount of 
weakness caused by anorexia, the child 
was compelled to remain in bed most of 
the time for the last year. Dyspnoea was 
so great that the child slept in a sitting 
posture. The child was very nervous and 
trembled when he was touched. He was 
very bright mentally. There was con- 
stant and rapid emaciation. Concen- 
trated food was given, which the patient 
took quite well. There was extreme 
hyperaesthesia of the skin. The digestion 
was quite good, and although the bowels 
moved sluggishly, they did not require 
much medicinal treatment. Fruit and fruit juices acted as laxatives. There was a 
curvature of the spine from left to right. mo>t marked in the dorsal vertebra. The 
urine was examined several times. It showed no evidence of pus or blood, no 
albumin and no sugar. There was a slight indican reaction. Xo acetone, no casts. 
no morphotic elements, microscopically. 

The case was hopeless from a medical standpoint, as the growth was constantlv 
increasing. The child suffered constantly from insomnia and great dyspnoea, requir- 
ing constant soporifics and narcotics. In spite of the grave prognosis, the family 
hoped that surgical measures might afford some relief. 




X 



Fig. 290. — Spindle-cell Sarcoma. 
The prominence of the tumor shows 
by contrast the emaciation of the 
body. (Original.) 



886 



ABNORMAL GROWTHS. 



As the tumor frequently appears to show a distinct pointing, this latter 
condition suggesting fluid, an anaesthetic was given with the assistance of Dr. J. W. 
Wurthman. The anaesthetic was badly borne and I succeeded with difficulty in 
making two exploratory punctures. 

An x-ray examination, to verify the clinical data, was made by Dr. C. Beck, to 
whom the case was referred. The heart could be plainly seen pulsating on the right 




Fig. 291. — Anterior View of the Tumor. Showing also the position of the 
displaced heart and the enlarged veins. (Original.) 



side. No definite satisfactory data could be learned concerning the tumor, on 
account of the restlessness of the patient, and the child was removed to St. Mark's 
Hospital and operated. The child died soon after the operation. 

A specimen of the tumor, removed during the operation, was sent by me to Dr. 
Mandlebaum, for a pathologic examination. He reported the tumor to be a spindle 
cell sarcoma in a rather active state of growth, on account of the large number of 
mitoses present. The fluid contained simply red blood cells and no pus. 



EN CHONDROMA'! A. 887 

Sarcomatous growths iu children are quite rare, though met with from 
time to time. Thus Mauderli, in the Children's Hospital of Basle, Swit- 
zerland, reports for the last twenty years that he treated a total of 10 
patients: T boys and 3 girls, of whom 4 were under 3 years of age, 3 were 
between 3 and 6 years, 1 was between 6 and 9 years, and 2 were between 
( J and 12 years. 

As but one case of malignant sarcoma was met with in this hospital 
in the course of the last twenty years in children as old as the case here 
reported by me, I feel justified, in adding mine to those already recorded. 

The interesting points about my case were : (1) The displaced heart — 
the heart being immediately behind the right nipple. The pulsations and 
apex-beat could be distinctly felt and seen about two finger-breadths below 
the right nipple. (2) The intense dyspnoea caused by pressure of the 
tumor. (3) Constant cyanosis and oedema of the limbs, due* to interfer- 
ence with the return circulation to the right side of the heart. 

Carcinoma. 

Carcinoma is occasionally found in children. Malignant growths of 
this kind have been diagnosed and verified by microscopical examinations. 

Lipoma. 

Fatty growths are occasionally seen in children. They occur on the 
scalp, on the back, and I have seen them on the buttocks. They require 
the same treatment as fatty growths in adults. (See article in the "New- 
born Baby" on "Congenital Sacral Tumor.") 

EXX'HONDROMATA. 

These hard growths are usually found on the fingers and toes. They 
are found in the neighborhood of the joints with which they are closely 
allied. A case of this kind which had several tumors removed, occurred in 
my practice : — 

Mary B., 10 years old. 

Family History. — Father healthy. Mother died of carcinoma of the uterus. 
Has one sister who is healthy and married. 

Patient's History. — Was breast-fed during infancy. Suffered with no gastric 
or enteric disorders. Had measles when several years old. Is not subject to any 
chronic disease. Her extremities are normal excepting the affected hand. The 
mother stated the tumors had been present soon after birth. They were not painful 
nor did they cause discomfort, so nothing was done until the child reached this age. 
The case was referred by me to the surgical service of Dr. S. M. Landsman, who re- 
moved the growths. The case made a perfect recovery. 



ABNORMAL GROWTHS. 



Spina Bifida. 

Abnormal growths are frequently found in the lumbar region asso- 
ciated with the spinal cord. They are frequently seen in cases of hydro- 
cephalus. A case of spina bifida is reported in the chapter on "Malforma- 
tions of the Spine.* 7 

Axgeioma. 

Angeioma. — Large vascular growths are occasionally seen in children. 
A case of this kind was seen by me. which I describe in the chapter on the 
"New-Born Baby," page 53. 




Fig. 202. — Enchondromata Involving the Thumb and 
Index Finger. (Original.) 



Papillomata. 

This growth is occasionally seen in the larynx of infants and children. 
It may be congenital. 

Symptoms. — Marked dyspnoea is usually a prominent symptom. This 
dyspnoea increases with the enlargement of the growth. There is also a 
husky voice, which increases in severity. The symptoms are very marked 
at night, but are much less, and frequently disappear entirely, during the 
day. Cough may also be present, but no expectoration. There is no fever. 
The diagnosis is usually made by a laryngoscopy examination. When the 
same symptoms appear for weeks and months a laryngeal growth should 
be suspected. 

Treatment.— Removal of the growth with an anaesthetic is absolutely 
necessary. The danger in removing the growth should always be borne in 



(JKAM LOMATA. 881) 

mind, hence the surgeon should be prepared to perform a tracheotomy if 
necessary. Intubation of the larynx will relieve the difficult breathing; at 
the same time there is danger of pushing some of this growth with the tube, 
thus obstructing the caliber of the same. Kelapses are common. 

Gran d lom ata. 1 

These growths are frequently seen at the site of the wound following a 
tracheotomy. They resemble a mass of exuberant granulations. 

Prof. A. Rosenberg, of Berlin, collected 231 cases of laryngeal tumors 
in children. Some of them were subjected to tracheotomy, others received 
endo-laryngeal treatment preceded by tracheotomy. In another series of 
eases persistent endo-laryngeal treatment was resorted to without perform- 
ing tracheotomy. This latter method yielded the better results. 



In Part II., Page 33. will be found article on "•Granuloma." 



PART XL 

DISEASES OF THE SPINE AND JOINTS. 



Pott's Disease. 1 



This disease derives its name from Percival Pott, who described it 
in 1779. "It is a chronic destructive process which begins in the bodies 
of the vertebras. The bodies of the vertebra? support the weight of the body. 
As the disease progresses the weakened parts give way. and the upper seg- 




Fig. 208.— Pott's Dis- 
ease | Langerhans I . Ky- 
phosis of dorsal vertebrae, 
the result of caseous tu- 
berculous periostitis and 
osteomyelitis. Destruc- 
tion of three thoracic ver- 
tebrae. Two-thirds nat- 
ural size. 



ment inclines forward. An angular posterior projection, kyphosis, is 
formed which is the characteristic deformity of the disease." 

Etiology. — "Pott's disease may appear at any period of life, from 
earliest infancy to old age. but like all forms of tuberculosis of the bones, 
it is most common in the first ten years of life, and 50 per cent, of the 
cases begin between the ages of 3 and 5 years, inclusive. 

"The lower segment of the spine, including the dorso-lumbar region. 
is most often involved. Cervical disease is relatively infrequent (cervical. 



1 The table of differential points between Pott's Disease and Rickets will be 
found on page 356. 
(890) 



POTTS DISEASE. 891 

7 V 2 per cent.; dorsal, 08 per cent.; lumbar, 24 per cent.). The death 
rate is at least 25 per cent. The course of the disease is most protracted in 
the middle region; it is shortest in the cervical region, its duration vary- 
ing in favorable cases from two to five years. 

"When the local resistance overcomes the tendency to degeneration, 
the process of repair begins. The tuberculous products are absorbed or 
enclosed, and ankylosis between the two segments of the spine is estab- 
lished by means of a union, in part fibrous, cartilaginous, and bony. Firm 
union is long delayed, and the deformity may increase long after the 
disease has become inactive" (Whitman). 

Pathology and Bacteriology. — "The first indications of disease are 
most often found beneath the fibro-periosteal layer of the anterior longi- 
tudinal ligament. From this point the granulation tissue advances along 
the course of the blood-vessels into the adjacent hone, extending from 
one to another until several bodies are more or less involved. The disease 
is accompanied, in many instances, by an abscess, which may be of suffi- 
cient size to cause special symptoms; or the tuberculous process may find 
its way to the posterior part of the vertebral bodies and thus involve the 
spinal cord, causing paralysis. Abscess is most common as a complication 
of disease of the lower part of the spine, where it may be detected in at 
least 50 per cent, of the cases. Paralysis most often complicates disease 
of the upper dorsal region, appearing in about 10 per cent, of the cases 
in which this part of the spine is involved. The primary infection is no 
donbt due to the entrance of the tubercle bacillus/' 

Anatomical Landmarks. — "The atlas is on a line with the hard palate. 
The axis is on a line with the free edge of the upper teeth. The transverse 
process of the atlas is just below and in front of the tip of the mastoid 
process. The hyoid bone is opposite the fourth cervical vertebra. 

"The cricoid cartilage is on a line with the sixth cervical vertebra. 

"The upper margin of the sternum is opposite the disc between the 
second and third dorsal vertebrae. 

"The junction of the first and second sections of the sternum is op- 
posite the fourth dorsal vertebra. 

"The tip of the ensiform cartilage is opposite the lower part of the 
body of the tenth dorsal vertebra. 

"The anterior extremity of the first rib is on a line with the fourth 
rib at the spine, the second with the sixth, the fifth with the ninth, the 
seventh with the eleventh. 

"The scapula covers the second and the seventh ribs, its lower angle 
being opposite the center of the eighth dorsal vertebra. 

"The root of the spine of the scapula, the glenoid cavity, and the 
interval between the second and third dorsal spines are in the same plane. 

"The most constant landmark from which to count is the spinous 



£92 DISEASES OF THE SPIXE AND JOINTS. 

process of the fourth lumbar vertebra, which is on a line with the highest 
point of the crest of the ilium. The umbilicus is near the same plane. 

"The tip of the coccyx is opposite the lower border of the symphysis 
pubis." 

Symptoms. — If the upper part of the spine is affected, a stiffness of 
the neck usually exists. If the lower part of the spine is affected, limping 
will be noticed, hence awkwardness in walking in very anaemic children 
should always be looked upon as suspicious. 

"The limitation of motion due to muscular spasm, to pain, and to the 
local disease is an important factor in diagnosis. This, together with the 
deformity, may be demonstrated by bending the patient's body directly 
forward to the fullest extent. An object is next placed on the floor, ami 
the patient is directed to pick it up. If this is done awkwardly by squat- 
ting or kneeling, it demonstrates weakness and stiffne->. The patient 
should next be placed prone upon a table, and the surgeon should test the 
flexibility of the spine by lifting the legs and swaying the body from side 
to side. The range of extension at the hips may be tested at this time by 
holding the pelvis against the table with one hand, while the thigh is over- 
extended with the other. This is the test for the slight degree of psoas 
contraction that is often present on one or both sides in disease of the 
lower region. 

"The flexibility of the upper part of the spine may be tested by vol- 
untary and passive movements of the head in various directions, and the 
range of motion of the occipito-atlo-axoid joints by holding the neck while 
the patient nods and turns the head from side to side, 

"The character and the extent of the deformity, if it be present, should 
next be investigated. Xote the contour of the spine. Any change from 
the normal are. in childhood, suspicious circumstances. Note the elastic- 
ity of the spine. If when the child is bent forward the spine forms a long, 
regular, even curve, disease is unlikely. If there be a break in the outline, 
and if one part remains rigid and another bends, disease may be suspected.*' 

Pott's disease in the lower region of the spine presents the following 
characteristics : — 

1. Pain. — The pain is referred to the lower part of the abdomen, to 
the genitals, to the loins, or to the thighs. 

2. Gait. — The waddling gait which has been described under general 
symptomatology is characteristic of disease in this region. In some cases 
there is a limp. 

3. Attitude. — Usually an abnormal erectness and sometimes an ex- 
aggerated lordosis; in some instances a lateral inclination of the body. 
Unilateral psoas contraction and the attendant limp are often present. 

4. Stiffness. — Muscular rigidity of the lumbar region interferes 
directly with almost everv attitude and movement. The effect of this 



l'"l rS DISEASE. 

.-tirlness and of tiu j accompanying weakness may be demonstrated by the 
popular method of asking the child t<> pick up a coin from the door. In 
this region of the spine the symptoms are usually weil marked before the 
stage of deformity, flexion of the legs, the effect of - - ^traction; and 
abscess are present in perhaps a third of the cast s. 

Pott's disease of the middle region is characterized by the following 
..iiarities : — 

1. Pain is referred to the lateral region of the thorax or to the front 
of the body. It is a common symptom. It is noted after sudden move- 
ments or after compressing the chest, as when the child is suddenly lifted 
from the rloor. 

2. Respiration. — If the disease i- at ail active, a grunting respiration 
is usually present, especially after exertion. This i> the most characteristic 
of all symptoms, especially so in young subjects. 

3. Attitude. — This is not always distinctive, but usually there is a 
peculiar shrugging squareness of the shoulders; occasionally a lateral in- 
clination of the body. The head is often inclined backward. The neck 
seems short on account of the elevation of shoulders. 

4. Deformity. — The deformity is usually prominent and it appears 
early in the disease. 

■3. Complications. — The most common complication of dorsal disea-e 
is paralysis, abscess being less frequent than in the lumbar region. Flat 
chest and chicken breast may be secondary deformities. 

Pott's disease of the upper region presents the following peculiari- 
ties : — 

1. If the uppermost cervical vertebrae are diseased, the pain is referred 
to the head, particularly to its lateral and posterior aspects. In disease of 
the middle cervical region it is referred to the neck, or to the shoulders 
or chest. 

2. The weakness and stiffness are manifest by the attitude. The head 
cannot be turned freely. If the disease be in the occipito-axoid region, 
the nodding and rotary motions are restricted. The chin is often depn - 
and slightly turned to one side. Lateral distortion resembling torticollis 
usually occurs when di-ease is nearer the middle of the cervical region. 

3. The bony deformity is often slight or absent, but thickening of the 
tisfi es about the spine and local sensitivene>s to lateral pressure are usn- 
ally present. Retro-pharyngeal abscess is not uncommon when the atlo- 
axoid region is involved. 

Complications. — (a) Abs ss; / Hysis: About 25 per cent, of 

all cases have abscess. An abscess situated in the atlo-axoid region often 
burrows into the retro-pharyngeal space. It may involve the cranial cavity 
when this occurs : symptoms of meningitis will be noticed. When an 
abscess forms from disease of the middle cranial region it usually opens 



894 -DISEASES OF THE SPINE AND JOINTS. 

on the side of the neck, before or behind the sterno-cleido mastoid region. 
When abscess follows disease in the dorsal region it burrows through the 
thorax. It can be detected by the physical signs accompanying pain (see 
chapter on "Empyema'"). 

When it burrows downward it may give rise to an iliac or lumbar ab- 
scess. "In disease of the lumbar region, the abscess, if superficial to the 
ilio-psoas muscle, may point in the neighborhood of the anterior superior 
spine, or pass through the inguinal ring. The true psoas abscess first dis- 
tends the iliac region, and then passing into the thigh, appears in Scarpa's 
space. In large abscesses of this character the pus may find an exit in the 
loin at the triangle of Petit, or in the gluteal region through the sacro- 
sciatic foramen. 

"In rare instances the abscess may find an opening within the body, 
and burst into the lungs, the intestines, or elsewhere. 

"As a rule abscess causes but little difficulty in diagnosis, because it is 
a late symptom, appearing after the diagnosis of Pott's disease has been 
established. It is more often an early symptom in the upper and lower 
regions of the spine, but in any event it is always accompanied by symp- 
toms of the underlying disease of the spine/ 3 

Paralysis. — The symptoms of Pott's paralysis are "an awkward stumb- 
ling gait, weakness, and finally an inability to stand. The lower limbs are 
'stiff at times. The reflexes are increased. Control of the bladder may be 
retained, but often there is active incontinence; that is, the bladder emp- 
ties itself from time to time. If the pressure is directly upon the reflex 
centers in the lumbar enlargement, there may be passive incontinence or 
dribbling of urine. If the pressure is below the reflex centers, the bladder 
is not affected, and the symptoms of numbness and weakness resemble those 
caused by neuritis." 

Differential points concerning abscess : — 

1. Abscess of the cervical region must not be confounded with the 
symptoms of enlarged tonsils, adenoids, or with so-called croup. It must 
also be distinguished from the simple acute abscesses of this region. 

2. Abscess of the thoracic region is to be distinguished from those 
secondary to disease of the lung or of the chest wall. 

3. Abscess in the loin or inguinal region may be mistaken for the 
acute or chronic abscess due to : — 

(a) Perinephritis. ^ These are usually of acute onset and are ae- 

( companied by constitutional disturbances. 
( There may be secondary rigidity of the spine, 

(b) Perityphlitis. J but no deformity, as is usual in Pott's dis- 

(^ ease at the stage of abscess formation. 

(c) Sacral or iliac disease. The symptoms of Pott's disease are lacking. 

(d) Hernia. 



POTT'S DISEASE. 



895 



The paralysis of Pott's disease musl be distinguished from 

1. Simple weakness. 

2. In jury to the cord. 

3. Tumors of the cord. 

4. Syphilitic disease of the cord. 

The weakness and stiffness caused by Pott's disease in the lower region 
may be simulated by lumbago, rheumatism, sciatica, and by the effect of 
injury or strain. Lumbago, rheumatism, and sciatica are uncommon in 
childhood. They are usually of sudden onset. Sciatica is usually uni- 




Fig. 294. — Pott's Disease. Case of Harry F. (Original.) 

lateral; the pain of Pott's disease is usually bilateral. Strains and other 
injuries have, as a rule, a well-defined history. 

Prognosis. — This should be cautiously given. While most cases seen 
by me ended fatally, several cases improved and recovered entirely. Years 
of patient treatment are necessary, and occasionally the most severe cases 
mav end in recoverv. 



Harry F., 4 years old. 

Family History. — Father and mother are unhealthy, weak and very poor. One 
child has died of summer complaint. Another, two years younger, is inclined to 
cough, and was operated by me for empyema. 



896 DISEASES OF THE SPINE AND JOINTS. 

Personal History. — The child was born and has since then lived in a tenement 
house, in a densely populated section of the city. He was a bottle-fed infant, and 
lias been constipated since birth, although he suffers with diarrhoea in summer. 
Has always been a frail and sensitive child. Has had measles and bronchitis, and 
is constantly troubled with some catarrhal affection. The child was late in walking, 
late in talking, and late in dentition. The general development shows backwardness 
when compared with a normal child. A slight deformity of the spine was first 
noticed when the child was about 2 years old. It has increased in prominence since 
that time. There is no distinct evidence of tuberculosis that can be made out in the 
lungs. The glands are not enlarged, there is no cough or expectoration. No evidence 
of fever. 

The treatment consisted in giving codliver-oil and creosotal internally from 2 
to 5 drops, three times a day. Friction of the body and general hygienic measures 
were instituted. Great stress was laid on the nourishment of the body. Cream, 
butter, eggs, cereals, and vegetables have been given constantly. 

Orthopaedic Treatment. — For the relief of the deformity, a supporting brace 
fitted to the body like a corset, similar to a Bradford frame, had been used for over 
six months with little improvement, therefore the case was sent to Dr. Ashley for 
a plaster-of-Paris corset. This treatment has been veiy successful, and the child 
is progressing favorably. 

Treatment. — When pus is present nothing but surgical treatment 
should be considered. Surgical treatment is not always necessary. The 
majority of cases require support by means of (a) spinal splint; (b) spinal 
brace; (c) plaster jacket. 

Either of these must be properly applied by a competent surgeon. I 
have seen some very disagreeable accidents due to a too tight plaster corset. 
For details in connection with the application of braces or plaster jackets 
the reader is referred to text-books on orthopaedic surgery. 

Medicinal Treatment. — This consists in giving restoratives such as 
codliver-oil, iron, and arsenic. Creosotal can be given with the codliver- 
oil. A rigid diet such as cream, butter, milk, cereals, eggs, vegetables, and 
fruits is indicated. 

If the child lives in the city a change to the seashore or to the moun- 
tains will sometimes improve the chances of recovery. 

Flatfoot in Children. 

Children are not born flatfooted. Very heavy children are predis- 
posed to flatfoot, especially if rickets is present. Laxity of the knees i- 
usually found associated with this condition. 

Treatment. — Careful orthopaedic treatment is necessary. This usu- 
ally consists in wearing a properly fitting shoe in which the arch is sup- 
ported with the aid of a stiff steel or celluloid plate. At times a soft pad 
of felt only is necessary. 

E. W. Lovett. of Boston, has contributed to the literature of this 
subject, and the reader is referred to his writings for details on this matter. 



LATERAL CURVATl RE OF THE SPINE. 



897 



Lateral Curvature of the Spine. 

A very frequent condition seen in weak children is curvature of the 
spine. 

Etiology. — Children that were bottle-fed in infancy and especially 
those having- rickets usually develop this condition. Anaemic children and 




Fig. 295. — Schoolgirl, Showing Lat- 
eral Curvature of the Spine. Due to 
Faulty Position. (Original.) 



Fig. 296.— Lateral Curvature of 
Spine. Same girl. Arms folded. (Orig- 
inal. ) 



those with flabby and atonic muscles are susceptible. It is especially due 
to faulty habits of posture in the schoolroom. 

Symptoms. — Unless the child is undressed, no special symptoms may 
be noticed. At times a difference in the height of the shoulders and in the 
hips will be apparent. Pain is usually absent, although I have heard chil- 
dren, especially older girls, complain of backache constantly. 

Prognosis. — This is usually good. 

Treatment. — Gymnastics and exercises such as dumbbells and pulley 
weights under the guidance of a competent instructor will usually develop 



898 DISEASES OF THE SPIXE AND JOINTS. 

the special muscles and correct this deformity. The sedentary life of a 
boy or girl so affected should be changed to an outdoor active life. The 
diet should be largely composed of proteids, such as meat, milk, eggs, and 
cereals. Cold sponging or a shower bath followed by friction of the sur- 
face should be prescribed daily. Internally strychnine or mix vomica. If 
the patient is not well-nourished, butter, cream, cod liver-oil, and malt 
extract should be ordered. 

Mechanical Appliances. — The use of a spinal brace is frequently ad- 
vised. It is neither scientific nor beneficial, and certainly does not remedy 
this condition. 

llORBUS COXAEIUS (HlP-JOIXT DISEASE: TUBEEC'ELAE HlP-JOIXT 

Disease). 

Coxitis, commonly known as tuberculosis of the hip-joint, is not easily 
diagnosticated in the primary stage. 

The age is no hindrance to the development of this disease, as it 
usually appears between the fifth and tenth year. 

Coxitis can be found in apparently healthy children, showing no sign 
of scrofulosis. 

1. They complain of tenderne— . 

2. Impediment of locomotion of the affected extremity. 

3. The change of the position. 

4. Local changes in the region of the joint. 

Symptoms. — The pain is one of the earliest symptoms and expresses 
itself by a feeling of tenderness in the affected joint or in the knee. The 
knee is quite characteristic in this affection and serves a good center for 
deception. In the knee no changes are directly noticeable ; there i> no 
impediment to locomotion. When the pain can be located in the knee- 
joint the pathological process in the hip-joint is usually fully developed. 
When children complain of pain in the knee-joint it is always wise to 
examine the hip. One of the most characteristic symptoms is the in- 
variable cry at night. 

The child will cry frequently and will suddenly awaken at night, with 
pain along the thigh not pointing to a distinct spot, hut showing that the 
pain is diffused along the leg; this symptom is rarely absent in true 
coxitis. 

At the earliest stage of coxitis the pain is trivial, but instinctively 
the patient tries to use the healthy limb and not the unhealthy one. This 
is one of the causes of limping. AYhen tenderness can actually be located. 
then locomotion is also limited. When this exists, difficulty in abduction 
and adduction appears. 

When examining by grasping the affected limb with one hand and 



CONGENITAL DISLOCATION OF THE Mil'. 



899 



supporting the small of the baci with fche second hand, a distinct resistance 
of the muscles can be felt. 

TUBERCULOUS COXITIS (DOUBLE). 

('. M. 10 years old, girl. Duration of disease, in left hip six years, and 
right hip five years. No history of exanthematous diseases. Treated at the Post- 
graduate for seven months in orthopaedic ward. An erasion of disease in left hip 
at thi^ time. 

Examination. — Right hip flexed to 90°, left hip flexed to about 95°. Right hip 
in adduction 10°, distinct spasm of the adductor muscles. Left hip in adduction 35°, 
slight spasm of the adductor muscles. Motion in right hip 10°, in left hip 20°. 
Right great trochanter two inches above Xelaton's line. Apparently no abscesses. 
Left trochanter almost denuded by erasion, only slightly above Xelaton's line. 
Many abscess scars, all healed. 

Treatment. — Modified Gant on right side, forcible correction of the left side, 
with tenotomies. 





Fig. 297. — Tuberculous Coxitis — Front 
View. 



Fig. 29S. — Tuberculous Coxitis — Side 
View. 



Congenital Dislocation of the Hip. 

This is the most frequent form and the most important of the con- 
genital dislocations. 

Etiology. — Faulty development of the acetabulum and the head of 
the femur combined with laxity of the capsule and possibly pressure upon 
the flexed thigh are supposed to be the causes of this condition. The dis- 
placement is usually upon the dorsum, although it may take place forward 
or upward. It is most frequent in females. Whitman states that 85 per 
cent, occur in females. It is usually seen unilateral. I have seen many 



Illustrations Figs. 297 and 298 are furnished through the courtesy of Dr. 
Dexter Ashley. 



900 



DISEASES OF THE SPINE AND JOINTS. 



cases bilateral. Sometime^ a peculiar family predisposition seems to exist, 
as several children in the same family have this deformity. 

Symptoms. — Unilateral Dislocation: The child limps when it begins 
to walk. The abdomen is very prominent. There is an abnormal lordosis. 
The buttocks appear enlarged. The thighs are usually separated and there 
is an increased breadth of pelvis. Shortening is difficult to detect in the 
beginning of the disease, but if the child grows older and the condition 




Fig. 299. — Congenital Hip Dislocation. Cases occurred in the practice of 
Dr. Dexter Ashley. 



has been neglected, then a shortening of several inches may sometimes be 
detected. Such children are easily fatigued. 

Bilateral Dislocation. — The pelvis is broadened and the thighs are far 
apart when the patient stands or walks. The limp is exaggerated and the 
child waddles. The lordosis is very marked. 

Treatment. — Eeplacement by traction by extreme abduction and 
flexion with prolonged fixation in the attitude of extreme abduction known 
as the Lorenz treatment, is frequently successful. In some cases the 
above treatment is unsuccessful and a radical operation must then be 
performed. 



M 



PLATE XXX 



X-ray of Congenital Dislocation of Hip. 



KNEE-JOINT DISEASE. 901 

G. L., male, 9 years old; A. L., female, 6 years old; H. L., female, 4 years old. 
Three out of five children in one family, of Irish parentage. No previous history 
of lameness. 

G. L., double posterior dislocation; muscular; great telescopic motion; right 
side has a shortening of 2 l / 4 inches, left side 2 3 / 4 inches, as per Nelaton's line; head 
and neck apparently well developed; thighs flexed adducted. and rotated inward; 
marked lordosis; walking ungainly and laborious; limited motion in abduction 
and extension; feet inclined to be flat; can stand in almost normal position except 
lordosis. Skiagraph reveals very well-developed neck on each side, the right inclined 
to coxa varus; head on each side inclined to be conical; acetabula rather shallow, 
but well formed otherwise. Advised no operation as the child was too old, and the 
circumstances of the family would not admit of good after-treatment. 

A. L., right posterior dislocation; distinct limp; limb carried slightly in ad- 
duction ; shortening 1 1 / 2 inches ; neck short and straight, or coxa valgus. Skiagraph 
verifies above observations, and shows an apparently poorly formed acetabulum, with 
considerable thickening. Preternatural mobility in all directions except abduction. 
Operation advised and performed. Transposition secured. 

H. L., 4 years old; posterior dislocation; 3 / 4 inch shortening; limp well 
marked; neck and head rather short but of normal angle; preternatural mobility in 
all directions except abduction. Skiagraph reveals short head and neck, apparently 
well formed acetabulum. Operation performed. Very good result, but might have 
been improved upon if child had been brought in for after-treatment. 

Knee- joint Disease. 

This is a chronic tuberculous inflammation due to an osteitis of the 
femur or tibia. It may begin as a synovitis similar to hip-joint disease. 

Etiology. — Traumatism is usually the exciting factor, as in hip-joint 
disease. 

Pathology. — The pathological lesions are those of tuberculosis. The 
tubercle bacillus is usually found, although it may be absent. The lesions 
spread and sometimes cause complete destruction of the joint. A char- 
acteristic swelling noted in tuberculous knee-joint is caused by an infiltra- 
tion of the soft parts with a gelatinous substance which must be attributed 
to a tuberculous process. 

Symptoms. — Children old enough to complain will describe pain when 
moving the joint. A limp is noticed when walking. A swelling of the 
joint gradually appears. The knee assumes a flexed appearance which is 
quite typical of this condition. As a result of the swelling in the joint, 
motion is limited, and the pain at times is very severe. Fever may or may 
not be present. In a case seen by me recently, although a large quantity 
of pus was present, no fever could be detected. This condition was one of 
the usual "cold abscess type." 

Diagnosis. — This depends on the limitation of motion, on the swell- 
ing, and on the pain. It does not resemble rheumatism owing to the affec- 
tion being limited to one joint. In rheumatism there is fever, at times 
very high fever, inflammation, swelling, and a sudden onset of symptoms. 
Just the reverse condition is found in knee-joint disease. 



902 DISEASES OF THE SPINE AND JOINTS. 

Prognosis. — The prognosis as a rule is good. Fully 90 per cent, of 
cases recover, according to Moore. When, however, cases are neglected, 
ankylosis of the knee-joint results. 

Treatment. — Eest in bed, assisted by proper hygiene and a good sup- 
porting diet, constitute the general line of treatment to be pursued by the 
general practitioner. The deformity requires careful orthopaedic treat- 
ment. A case of this kind usually requires a knee-splint or a plaster cast. 
It is self-understood that only one competent to do this should guide the 
treatment. For details regarding the application of knee-splints, etc., the 
reader is referred to works on orthopaedic surgery. 

Diseases of the Ankle-joint and Tarsus. 

Tubercular disease frequently affects the ankle and tarsus. The same 
pathological manifestations described in hip and knee-joint diseases are 
found here. 

Symptoms. — As a rule a limp will be noticed. Associated with this 
there is swelling of the joint, limitation of motion, and in some cases fever; 
in other cases, atrophy of the muscles of the leg. The superficial veins are 
usually enlarged. 

Diagnosis. — The slow onset of the symptoms associated- with swelling 
and the limp on walking will usually aid in establishing the diagnosis. 
It is important to exclude rheumatism by carefully examining other joints 
of the body. The diagnosis rests upon the disease being limited to one 
joint in addition to the symptoms above described. 

Prognosis. — The prognosis is usually good. Cases usually recover 
under proper management in six to nine months. 

Treatment. — The same treatment described in the article on knee- 
joint disease applies here. The parts should be given absolute rest. This 
can be secured by the use of plaster of Paris casts. The rest of the treat- 
ment is restorative. 

Wrist-joint and Elbow-joint Disease. 

This condition is rarely met with in children. When, however, tuber- 
culous manifestations exist the symptoms are the same as described in 
other tubercular joints. 

Treatment consists in securing rest and immobility of the parts with 
the aid of plaster casts. Pus, when present, requires surgical relief. The 
outcome of these cases is as a rule good. 

Joseph S., 10 years old, has been under the treatment of Dr. Dexter Ashley, to 
whom I am indebted for the illustration. The child was in an extremely ansemic 
condition, heart and lungs normal, no evidence of tuberculosis. Family history good. 
Local evidence of tuberculosis involving the elbow-joint, so-called bone tuberculosis. 



ACUTE ARTHRITIS. 



903 



The boy was able to run about, and excepting this arm seemed to be in a fair physical 
condition. A comparison of the healthy elbow-joint with the diseased joint is quite 
interesting. Dr. Ashley's treatment consisted in strict aseptic dressings, tight 
bandaging, a bandage to support the return circulation and general restorative treat 
ment. 




Fig. 300. — Tubercular Elbow-joint. 



Acute Arthritis (Infectious Osteitis: Acute Pueulext Synovitis: 
Acute Epiphysitis: Acute Osteomyelitis). 

This is an acute inflammatory condition involving a joint. It is 
always suppurative from the beginning; it is therefore a form of pyaemia. 
It is an infection originating at the bone in the medullary canal or in the 
joint. 

Etiology. — This condition may follow the acute infectious diseases, 
especially those which show a tendency to suppurative processes. It most 
frequently follow? measles, scarlet fever, and empyema. 

There seems to be no reason to believe that this disease owes its exist- 
ence to syphilis, tuberculosis, or scrofulosis. Some authors state that a 
history of traumatism lias preceded this infectious disease. 

Bacteriology. — Cultures taken of the purulent discharge usually show 



9Q4 DISEASES OF THE SPINE AND JOINTS. 

the presence of the streptococcus pyogenes or the staphylococcus. The 
point of entrance for the pathogenic bacteria may be either the skin, if 
abraded, the umbilicus, or the tonsil. In this manner the bacteria gain 
entrance to the circulation. 

Symptoms. — Distinct swelling of the joint can be made out, although 
the inflammatory condition is deep-seated. The joint is red and inflamed 
and has a glazed appearance. Fluctuation can be felt if properly palpated. 
The usual symptoms of inflammation, such as high fever and chills or 
rigors, are present. 

The joints most usually affected are best judged by studying Town- 
send's collection of cases : — 

Hip ' 38 cases 

Knee 27 cases 

Shoulder 12 cases 

Wrist 5 cases 

Elbow 4 cases 

Ankle 4 cases 

Fingers 2 cases 

Toes 1 case 

Sterno clavicula 1 case 

Diagnosis and Differential Diagnosis. — The diagnosis is easily made if 
we remember the rapidity with which this condition develops. It may 
resemble rheumatism, but the acute onset with the fever and the suppura- 
tion makes it easy to exclude rheumatism. Syphilis may resemble arthritis, 
but the fever and suppuration are never present in syphilis. 

Prognosis. — If the disease extends rapidly death may occur in a few 
days. The outcome of the case depends on recognizing the disease in its 
early stages, and on the rapidity with which the suppurative condition is 
relieved. 

Treatment. — The treatment is surgical. With aseptic care and atten- 
tion to surgical detail, pus should be evacuated and the joint properly 
immobilized. To prevent deformity fixation of the joint should be remem- 
bered. Restorative treatment should consist in giving arsenic, maltine with 
hypophosphites, in addition to concentrated food and general hygienic care. 
The surgical treatment should be given into the hands of a surgeon. 



PART XII. 

MISCELLANEOUS. 

CHAPTER I. 
DIETARY. 

Beverages. 

Albumin Water. — Stir the whites of 2 eggs into % pint of ice-water, 
without beating; add enough salt or sugar to make it palatable. Such a 
mixture is one of the best foods we have for substitute feeding an infant 
with digestive disturbances when we wish to temporarily stop all milk-food. 

Almond-milk. — Take two ounces of sweet almonds, scald them with boil- 
ing water ; after a few moments express them from the hulls ; then pour the 
hot water away. Put the blanched almonds into a mortar and pound them 
thoroughly, and add either 2 ounces of milk or 2 ounces of plain water. 
After this is thoroughly mixed, it is to be strained through cheese-cloth, 
and the strained liquid will be the almond-milk. 

Arrowroot Water. — Add 2 tablespoonfuls of arrowroot to 1 pint of 
water ; allow it to simmer for half an hour, stirring it constantly. 

Barley Water. — Take a tablespoonful of pearl barley, 1 grind it in a 
coffee-grinder, or pound it in an ordinary mortar; add 1 quart of cold 
water, and allow it to simmer slowly for about an hour. Strain and add 
enough water to make 1 quart. 

Beef Juice. — Expressed beef juice is obtained by slightly broiling a 
piece of lean beef and expressing the juice witli a lemon-squeezer. One 
pound of steak yields 2 or 3 ounces of juice. This is flavored with 
salt and given cold or warm. Do not heat enough to coagulate the albumin. 
This is very nutritious and usually well taken. It may be given at the 
rate of a tablespoonful three times a day. 

Cocoa. — For each large cup take a teaspoonful of cocoa and a tea- 
spoonful of sugar; mix to a paste with a little boiling water or milk; add 
balance of milk or milk and water, as richness is desired. Let it boil a 
minute, as boiling improves it. 

Chocolate (Unsweetened). — For each breakfastcup take 1 division, 
break in small pieces, and allow to melt; add milk or milk and water, as 



1 Prepared barley flour can be procured in pound boxes from the Healtb Food 
Company of New York City. 

(905) 



906 MISCELLANEOUS. 

richness is desired. Stir constantly. Bring to a boiling point and set 
aside to simmer. Sugar to taste. 

Eggnog. — Heat some milk to a temperature of 150° F.. but do not 
allow the milk to boil. When cold, beat up a fresh egg with a fork in a tum- 
bler with some sugar : beat to a froth, add a dessertspoonful of brandy, and 
fill up tumbler with the warm milk. 

Oatmeal Water. — Take a tablespoonful of ordinary oatmeal, and add 
1 pint of water. Allow it to simmer slowly for one hour and strain. Add 
enough water to make 1 pint. The same directions apply to making a 
household mixture of farina-water, and sago-water, using the same propor- 
tions as above. 

Rice Water. — One ounce of well-washed Carolina rice. Macerate for 
three hours at a gentle heat in a quart of water, and then boil slowly for 
an hour and strain. It may be sweetened and flavored with a little lemon- 
peel. Useful in diarrhoea, etc., when the flavoring is best dispensed with, 
and a little old cognac added. 

Yolk of Egg Lemonade. — Take the beaten yolk of 1 egg and add to 
it the juice of 1 / 2 lemon. Let stand five minutes, thus drawing oh* the raw 
taste of the yolk of egg. Add 1 teaspoonful of sugar and 8 ounces of water. 

White of Egg Orangeade. — Take the juice of 1 orange and 1 ounce 
of water, insert an egg whisk, and when the orangeade is in full agitation, 
add slowly the white of egg. Continue the whisking for two or three min- 
utes more. Add % teaspoonful of sugar. 

White of Egg Lemonade. — Leftwich 1 advises the following for a nutri- 
tive drink for febrile and wasting diseases : — 

B Lemons 2 

White of eggs 2 

Boiling water 1 pint 

Loaf sugar to taste. 

The lemon must be peeled twice — the yellow rind alone being utilized 
— while the white layer is rejected. 

Place the sliced lemon and the yellow peel in a quart jug with 2 lumps 
of sugar. Pour upon them the boiling water and stir occasionally. When 
cooled to the ordinary temperature, strain off the lemon-. 

Now insert an egg whisk, and when the lemonade is in full agitation 
add slowly the white of egg. Continue the whisking for two or three 
minutes more. While still hot. strain through muslin. Serve when cold. 

The white of egg will be found to impart a blandness which makes 
the addition of sugar almost unnecessary. 

This drink is very useful in the febrile diseases of children. It may 
be given simply as a lemonade, without mentioning the egg<, and will 

1 Edinburgh Medical Journal. 



D1ETAKY. 907 

thus be readily taken by the children and difficult patients. It also pos- 
51 ssi - antiscorbutic properties, which replace those lost from milk by boil- 
ing and sterilizing. 

Soups and Bkoths. 

Chicken Broth. — Cut up a small chicken, put bones and all, with a 
sprig of parsley, salt, 1 tablespoonful of rice, and a crust of bread, in a 
quart of water and boil for one hour, skimming it from time to time. 
Strain through a coarse colander. ■ 

Keller's Malt Soup. — Take of wheat-flour 50.0 (about 2 ounces). To 
this add 11 ounces of milk. Soak the wheat-flour thoroughly, and rub it 
through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which add 3 ounces of 
malt extract; dissolve the above at a temperature of about 120° F., and 
then add 10 cubic centimeters (about 2 1 / 2 drachms) of 11 per cent, potas- 
sium bicarbonate solution. Finally mix all of the above ingredients, and 
boil. 

This gives a food containing: — 

Albuminoids 2.0 per cent. 

Fat 1.2 per cent. 

Carbohydrates 12.1 per cent. 

There are in this mixture: 

Vegetable proteids 0.9 per cent. 

The wheat-flour is necessary, as otherwise the malt soup would have 
a diarrhceal tendency. The alkali is added to neutralize the large amount 
of acid generated in sick children. Biedert emphasizes the importance of 
giving fat, rather than reducing its quantity, in poorly nourished children, 
and cites the assimilability of his cream-mixture or of breast-milk in under- 
fed children as proof of his assertions. The author has used this malt 
soup most successfully in the treatment of athrepsia (marasmus) cases in 
which the children were simply starved. 

Mutton Soup. — Cut up fine 2 pounds of lean mutton, without fat or 
skin. Add 1 tablespoonful of barley, 1 quart of cold water, and a teaspoon- 
ful of salt. Let it boil slowly for two hours. If rice is used in place of 
barley, soak the rice in water over night, if it is to be boiled in the morning. 

Oyster Broth. — Cut into small pieces 1 pint of small oysters ; put them 
into 1 / 2 pint of cold water, and let them simmer gently for ten minutes 
over a slow fire. Skim, strain, and add salt. 

White Celery Soup. — Take 1 / 2 pint of strong beef -tea; add an equal 
quantity of boiled milk, slightly and evenly thickened with flonr. Flavor 
with celery seeds or pieces of celery, which are to be strained out before 
serving. Salt to taste. 



908 MISCELLANEOUS. 



Puddings and Desserts. 



Calf s-foot Jelly. — Thoroughly clean 2 feet of a calf, cut into pieces, 
and stew in 2 quarts of water until reduced to 1 quart ; when cold, take off 
the fat and separate the jelly from the sediment. Then put the jelly into 
a saucepan, with the shells and whites of 4 eggs well mixed together ; boil 
for a quarter of an hour, cover it, and let it stand for a short time, and 
strain while hot through a flannel bag into a mould. Flavor with lemon. 

Baked Apples. — Core and pare 2 tart apples; fill the core-holes with 
sugar; grate over the apples a little nutmeg; add a little water to baking- 
pan and put in oven and bake until the apples are soft. Serve with rich 
milk or cream. Sprinkle with icing sugar, if not sweet enough. 

Cornstarch Pudding. — Take 1 pint of milk, and mix with it 2 table- 
spoonfuls of cornstarch ; flavor to taste ; then boil the whole eight minutes ; 
allow it to cool in a mould. 

Custard Pudding. — Break 1 egg into a teacup, and mix thoroughly 
with sugar to taste; then add milk to nearly fill the cup, mix again, and 
tie over the cup a small piece of linen ; place the cup in a shallow saucepan 
half -full of water and boil for ten minutes. 

If it is desired to make a light batter pudding, a teaspoonful of flour 
should be mixed in with the milk before tying up the cup. 

Infant's Gelatine Food. — About 1 teaspoonful of gelatine should be 
dissolved by boiling in 1 / 2 pint of water. Toward the end of the boiling 
1 gill of cows' milk and 1 teaspoonful of arrowroot (made into a paste with 
cold water) are to be stirred into the solution, and 1 to 2 tablespoonfuls of 
cream added just at the termination of the cooking. It is then to be mod- 
erately sweetened with white sugar, when it is ready for use. The whole 
preparation should occupy about fifteen minutes. 

Junket of Milk and Egg. — Beat 1 egg to a froth and sweeten with 2 
teaspoonfuls of white sugar. Add this to 1 / 2 pint of warm milk; then 
add 1 teaspoonful of essence of pepsin (Fairchild) ; let it stand till it is 
curdled. The above is useful in typhoid and similar wasting diseases. 

Jelly Sugar (Price). — This is a combination of refined gelatine sugar 
and lemon acid. It is very well adapted for children over 2 years of age. 
It can be made in a moment by adding hot water. 

It is very nutritious 'and easily assimilated, and can be bought with 
any desired flavor. 

Predigested Eggs. — Break a fresh egg. After thoroughly stirring add 
to it 2 grains of caroid powder and stir thoroughly. The yolk is at once 
changed into a limpid liquid and soon, though not so quickly, the albumin 
is completely dissolved. This is done at a temperature of 70° to 80° F. 

Predigested Rice.— Take % pound of rice, add water, and boil until 
soft. Break grains by passing through a colander. Take, of bana-diatase, 



L 



DIETARY. 909 

8 grains/ and dissolve it in 1 aunce of water and add to the rice, which must 
be kept warm, but not hot. . Let stand for two hours at a temperature of 
105° F. When rice is thoroughly softened, season with salt, sparingly. 
Add a little cream if desired. Serve hot or cold. 

Rice Pudding. — Boil a teacupful of rice, drain off the water; add a 
tablespoonful of cold butter. Mix with it a cupful of sugar, a quarter tea- 
spoonful of ground nutmeg, and a quarter teaspoonful of cinnamon. Beat 
up 4 eggs very light, whites and yolks separately; add them to the rice; 
stir in a quart of sweet milk gradually. Butter a pudding dish, turn in 
the mixture, and bake one hour in a moderate oven. 

If you have cold cooked rice, first soak it in the milk, and proceed 
as above. 

Sago Pudding. — Same as above recijDe, sago being substituted for rice. 

Soft Custard. — Take of cornstarch 2 tablespoonful s to 1 quart of milk ; 
mix the cornstarch with a small quantity of the milk, and flavor; beat up 
2 eggs. Heat the remainder of the milk to near boiling; then add the 
mixed cornstarch, the eggs, 4 tablespoonfuls of sugar, a little butter, and 
salt. Boil the custard two minutes, stirring briskly. 

Tapioca Cream. — Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 
tablespoonfuls of sugar, 1 saltspoonful of salt, and 2 eggs. Wash the 
tapioca. Add enough water to cover it, and let it stand in a warm place 
until the tapioca has absorbed the water. Then add the milk and cook in 
a double boiler, stirring often until the tapioca is clear and transparent. 
Beat the yolks of the eggs. Add the sugar and salt and the hot milk. 
Cook until it thickens. Eemove from the fire. Add the whites of the eggs, 
beaten stiff. When cold, add 1 teaspoonful of vanilla. 

Modified Cows' Milk. 

Humanized Milk. — A pint of milk is set aside until the cream rises, 
and this cream is skimmed off and kept. To the milk remaining is 
added enough rennet to curdle it. The whey is strained off the curd and 
added, with the previously separated cream, to a pint of fresh cows' milk. 
This is known as humanized milk. In some infants it will be well borne 
during the first three months, and to this can he added farinaceous liquid 
for dilution if required. 

Pasteurized Milk. — This is really partially sterilized milk, and consists 
of sterilization at a temperature of 140° F. instead of 212° F., this sterili- 
zation to be continued for from twenty minutes to half an hour. Pasteur- 
ized milk should only be used during the twenty-four hours following this 
process. A good apparatus for this purpose is Kilmer's pasteurizing ap- 
paratus. 



American Ferment Company. 



MISCELLANEOUS. 

Predigested or Peptonized Milk. — This is milk in which the pro: 
are changed to pe ~ in other words, digested, by the addition and 

action of pancreatic ferment. This process may be stopped when partially 
performed, giving a product of which the taste is not objectionable; ot it 
may be carried on to complete peptonization, when the product has 
tter 3 lisagreeable taste. 

Method. — To partially peptonize milk, add to 1 pint of fresh c 
milk and 4 ounces of water. 5 grains of pancreatic extract and 15 grains of 
bicarbonate of soda. Allow this to stand at a temperature of 105° to 115° 
F. for five to twenty minutes, then bring to a boil to kill the ferment, or 
stand on ice to prevent its further action. If the milk is to be used at on 
neither of these latter is n ssary. 

peptonize the milk completely, allow the process to continue for 
one to two hours. After this time the addition of acid produces no coagu- 
lation. 

In infant-feeding it is better to peptonize a modified than a whole 
milk. Peptonized milk is frequently very useful in f ceding an infant with 
feeble digestive powers: but it is unwise to continue its use over too long 
a period, as then the infant's stomach, being called on to do no work, be- 
comes enfeebled from disuse, and gradually unable to perform its proper 
function. 

Whey. — By coagulating 1 pint of fresh (raw) milk by addin_ 
spoonful of essence of pepsin, and allowing this to stand, a solid curd is 
formed swimming in a liquid (whey This has the following composition: 
Proteids. .8 :it. : fat. 0.32 per cent.: sugar. 4.T9 per salts, 

0.65 per cent. : w .3 per cent. 

This at times makes a verv valuable food for infants in cast - : _ 

intestinal disorder, where the use of milk mi st f interdicted. 

ies like it. it is v . : b gestion, and does not irritate the stomach. 

When such whey is added to milk for an infant under 6 weeks take. 

of whey. 2 parts: milk. 1 part. This can be increased until equal parts 

of milk and whey sed for a child several months old. 

Preparation of > mi Wl :,. — Sw : whey is best made by the follow- 
ing method: For each pint of whey needed take 1 quart of raw milk 
zat-free milk, heated fa - : F. >. and add 8 cubic centimeters 

•rachms) of the essence of pepsin or some of the preparations of liquid 
rennet. This will precipitate the casein in the form of a curd, which is 
then broken up with a fork: the fluid which remains is the whey. This 
s -trained through two thick] se - >f boiled cheese-cloth and one thick- 
Borhent tton and slowly cooled to a temperature of 10° C. (50° 
and kept on ice until needed. If the whey is to be mixed with cream. 
it must first be heated t< 150° F.), in order to kill the rennet 

Whey mixtures should not be heated abc - C. (155* P.) 



DIETARY. 911 

if one wishes to keep safely under the coagulation-point of the lactalbiuuin. 
Add 1 teaspoonful of cane-sugar to each pint of liquid. 

Miscellaneous. 

Milk Toast. — Take 1 cupful of milk, V 2 teaspoonful of cornstarch, 1 / 2 
teaspoonful of butter, 2 slices of dry toast, 1 saltspoonful of salt. Scald 
the milk. Add the moistened cornstarch. Melt the butter in a saucepan; 
when hot and bubbling, pour in the hot milk slowly, beating all the time 
until smooth. Let it boil up once. Then add the salt. Toast 2 slices of 
bread. Pour the thickened milk over the slices. Let it stand a few 
minutes. Serve. 

Scraped Beef. — Scraped beef is prepared by scraping with a dull knife 
some raw or underdone lean beef. Add salt and serve on bread or biscuit. 

Scrambled Eggs. — Take 2 eggs, a pinch of salt, 2 tablespoonfuls of 
milk, and a small piece of butter. Beat the eggs lightly, add the salt and 
milk. Put the butter into a saucepan, when melted and hot, add the eggs. 
Stir until of a soft creamy consistency. Serve on buttered toast. 

Soft-boiled Eggs. — Drop 2 eggs into enough boiling water to cover 
them. Let them stand on the back of stove, where the water will keep hot, 
but not boil, for eight minutes. An egg to be properly cooked should never 
be boiled in boiling water, as the white hardens unevenly before the yolk is 
cooked. The yolk and white should be of a jelly-like consistency. 



CHAPTER II. 

THE ADULTERATION OF MILK. 

Formaldehyde in Milk. 

The adulteration of milk by the use of formaldehyde is be- 
coming more common than is generally suspected. For a time its 
use was a "trade secret;' but it has been so thoroughly advertised that every 
obscure individual who has a milk route is now familiar with the preserva- 
tive qualities of formaldehyde. In our large cities the health officers are 
on the watch, and hence in these its use is being curtailed, but in the 
smaller towns and villages the people have not this protection. It would 
be well, therefore, for physicians to guard agaiust this and keep it in 
mind when mysterious illness develops in milk-users. They should also 
be prepared to make an analysis of milk at any lime as to its freedom from 
the drug. This is a simple procedure, and yet one that requires consider- 
able technical skill in the use of some of the tests. The Lancet-Clinic gives 
the various methods for testing formaldehyde as laid down by Herman 
Harms, some of which are quite simple: — 

Rimini Test. — (A): Phenyl-hydrazine muriate, 0.5 gram; distilled 
water, 100 cubic centimeters; dissolve. (B) : Sodium nitroprusside, 0.5 
gram; distilled water, 30 cubic centimeters; dissolve. (C) Soda, U.S.P.. 
15 grams; distilled water, 60 cubic centimeters; dissolve. To 15 cubic 
centimeters of the suspected milk in a test-tube add 10 drops of A, mix 
and add 3 drops of B; mix and let 5 drops of C run in slowly on the side 
of the test-tube. In the presence of formaldehyde a blue color is instantly 
produced, changing, on standing, to red. On adding to the mixture of 
milk and solution A, 2 drops of ferric chloride solution, and then about 2 
cubic centimeters of concentrated hydrochloric acid, a red color is pro- 
duced, which later changes to orange-yellow. In sour milk the above-men- 
tioned blue is supplanted by green. The Rimini test is easily applied, and 
readily detects formaldehyde when present to the extent even of 1 part 
in 25,000 or 30.000. 

Phloroglucin Test.— Dissolve 1 gram of phloroglucin in 100 cubic 
centimeters of distilled water. Put 10 cubic centimeters of the suspected 
milk in a test-tube and add 5 cubic centimeters of the phloroglucin solu- 
tion; shake and add 1 cubic centimeter of solution of potassa (U.S.P.). 
If formaldehyde is present, a red color is developed at once, fading usu- 
(912) 



THE ADULTERATION OF MILK. 913 

ally, within five or ten minutes; hence the color must be observed at once. 
One part in 20,000 gives a decided reaction. 

Hehner's Test. — To 15 cubic centimeters of concentrated sulphuric 
acid in a test-tube add 1 or 2 drops of ferric chloride test solution (U.S. P.) 
and mix. Then pour upon this, in such manner as not to mix the layers, 
the suspected milk. A violet color indicates the presence of formaldehyde. 
In the case of cream dilute the cream with an equal volume of water, and 
then apply the test as above described. The violet color is sometimes pro- 
duced at once, but oftener not for five or ten minutes, and sometimes not 
for an hour or so, depending on the amount of formaldehyde present. By 
this test 1 part in 10,000 or 15,000 is readily detected. 

Liebermann Phenol Test. — In the presence of small traces of for- 
maldehyde, distill off from the milk a few cubic centimeters, and add to 
this 1 drop of very dilute aqueous phenol solution. Then pour this mix- 
ture slowly upon concentrated sulphuric acid in a test tube solution so as 
to form a layer. A bright crimson color appears at the zone of contact. 
This is easily seen in as little as 1 part in 200,000, and in greater propor- 
tion in 1 to 100,000. There is a milky zone above the red color, and, if 
more concentrated, there will be a whitish or pinkish precipitate. Some- 
times the zone will appear in about one hour, one-tenth of an inch below 
the line of contact. 

Hydrochloric Test. — Fifteen or 20 cubic centimeters of suspected milk, 
together with 2 or 3 cubic centimeters of strong hydrochloric acid, are 
boiled for a few minutes in a test-tube. A red coloration indicates for- 
maldehyde. Other tests are known, but they are more complicated and 
require apparatus or reagents not kept by the average pharmacist. The 
above tests are all simple in their application and afford a ready means of 
detecting formaldehyde in milk and cream. 

Remarks on tlte Foregoing Tests. — The Eimini test is highly recom- 
mendable. The reaction in sweet milk appears rapidly and with certainty. 
Hehner's test, as well as the phloroglucin and phenol tests, are very reliable 
and are all extremely sensitive. The hydrochloric acid test is very simple, 
but is not to be depended on ; it may show formaldehyde in most instances ; 
however, cases have come under our observation when it has utterly failed 
to show the reaction, probably because of the milk having undergone some 
unknown changes. The Liebermann test is simple, delicate, and shows 
formaldehyde very readily. 

As corroborative evidence, it is well, after the tests are finished, to 
let the suspected milk or cream stand in a warm place for twenty-four 
hours. A pure sample will invariably turn sour and separate. A sample 
which has been "doctored" with formaldehyde, however, will show, at the 
end of twenty-four hours, but a very slight separation, if indeed any at 
all, and will have but a slight odor. 



914 MISCELLANEOUS. 

A Word of Caution. — It is desirable that all test solutions be freshly 
prepared, especially the nitroprusside of sodium solution in the Rimini 
test, and that the suspected sample be as fresh as possible. Sour samples 
are difficult to test, and may yield variable results, because in these for- 
maldehyde' has been oxidized, and is no longer present as formaldehyde. 
In carrying out the tests for formaldehyde it is advisable to work the sus- 
pected sample and the one known to be pure side by side. Finally, do 
not expose your tests or have your milk placed where a bottle of formalde- 
hyde is being opened, for the vapor is very penetrating, and you thus may 
be easily led to misleading results. When formaldehyde has been found 
to be present by at least three of the aforementioned tests, it may be con- 
sidered that its presence has been shown. 



CHAPTER 111. 
THE EXAMINATION OF THE GASTRIC CONTEXTS IN CHILDREN. 1 

Chemical Examination. 2 

After the removed chyle is filtered it is ready for the following 
tests :— 

Hydrochloric Acid. — Free hydrochloric acid turns Congo-red a deep 
blue color: but as the presence of large quantities of lactic and other or- 
ganic acids gives the same reaction, and as the phlorogiucin-vanillin (Giinz- 
burg's reagent ) does not respond to the organic acids, it is better not to 
depend upon the simpler Congo-red test. One or two drops of the filtered 
stomach-contents are placed on a white porcelain dish; the same amount 
of the reagent is added and thoroughly mixed with a glass rod ; the dish 
is then gently warmed over the flame. The appearance of a bright cherry- 
red color on the edge of the residue indicates the presence of free hydro- 
chloric acid. 

To 10 cubic centimeters of the filtered chyle add 1 drop of 
phenolphthalein solution : to this add drop by drop from the burette a 
decinormal solution of potassium or sodium hydrate until after thoroughly 
stirring, a pink color persists: now read carefully the number of cubic 
centimeters of the alkali solution used, multiply by 10 and 0.00365 (the 
decinormal factor of HC1) and the result is the percentage of HO. If suf- 
ficient material is at hand, the estimation should be repeated to avoid pos- 
sible error. 

Lactic Acid (TJffelmann's Test). — One drop of the solution of ferric 
chloride is added to 20 cubic centimeters of the 1 / 2 per cent, carbolic acid 
solution : this is diluted till a transparent amethyst blue color is obtained. 
A few drops of the fluid to be tested added to a few cubic centimeters of 
this solution in a test-tube, change the amethyst-blue to a canary-yellow if 
lactic acid be present. On account of the presence of various other substances 
this test is sometimes not distinctive when the untreated chyle is used. A 
more certain procedure is to add to 10 cubic centimeters of the filtered 
chyle in a test-tube 110 cubic centimeters of ether: shake thoroughly; 



With a soft flexible catheter I syphon the gastric contents about two hours 
after feeding: if the stomach is irritable and children vomit, then the vomited 
material is used. 

2 T am indebted to Boas' valuable book on "Diseases of the Stomach" for many 
points in the chemical examination and methods used. 

(915) 



916 MISCELLANEOUS. 

allow the ether to separate: decant the ether into a clean test-tube; place 
the test-tube containing the ether in a glass of warm water till the ether 
has evaporated; add 5 to 10 cubic centimeters of distilled water to the 
residue, and test as above for lactic acid. 

Propeptone. — To 5 cubic centimeters of chyle, add 5 cubic centimeters 
of saturated solution of sodium chloride and 2 drops of acetic acid. A 
cloudiness or precipitate indicates proj>eptone, especially if the precipitate 
disappears on heating and returns on cooling. 

Peptone. — Filter out any propeptone from the last named; add an 
excess of sodium hydrate solution ; mix thoroughly and add 1 or 2 drops of 
a weak solution of copper sulphate Q-/ 2 per cent.); the appearance of a 
violet-red or old-rose color indicates peptone. This is the so-called biuret 
reaction which most peptones and albumoses give. 

Pepsin. — For this test we require uniform, small pieces of coagulated 
albumin; these should be little circular slices of hard boiled white of egg. 
1 centimeter in diameter and 1 millimeter in thickness, which may be 
preserved in glycerine. One of these discs is placed in a test-tube 
containing 5 cubic centimeters of filtered chyle and kept at a temperature 
of 99° F. ; if it has been already shown that hydrochloric acid is absent. 
1 drop or 2 of dilute hydrochloric must be added. The tube is observed 
every twenty to thirty minutes to note the progress of digestion and the 
time required for complete disappearance of the egg albumin. 

Rennet. — Add a few drops of chyle to 5 or 10 cubic centimeters of 
milk and place tube in water at a temperature of 99° F. 

Motility. — The motility of the stomach may be tested in various ways ; 
probably the salol-test, although open to many objections, is the most used. 

This test finds the foundation for its use in the fact that salol is not 
absorbed until it reaches the alkaline secretions of the intestine, by which 
it is decomposed. The test is untrustworthy when the stomach secretion 
is alkaline. The time between ingestion and the appearance of salicyluric 
acid in the urine is noted by examining the urine at intervals of one-half 
and one hour after taking 15 grains of salol (immediately after meal). 
If salicyluric acid be present in the urine, the addition of a few drops of 
a solution of ferric chloride gives a violet color. If the appearance of the 
test be delayed longer than an hour or an hour and fifteen minutes, the 
motility is usually considered below normal. 



CHAPTER IV. 
URINE. 

Method of Collecting Urine. 

In collecting urine from an infant we can apply a pad of sterile ab- 
sorbent cotton or a flat sterile sponge to the vulva. After urination the 
urine absorbed can be filtered into a bottle. If the urine thus secured is 
not sufficient for examination, the method can be repeated several times. 
In boys the smallest size rubber ice-bag can be drawn over the genitals and 
a specimen secured in this manner. 

If for any reason this method cannot be carried out, and it is vital 
that the examination be made, then an infant's size catheter may be used 
to draw oh* the urine. 

The First Urine. 

The first urine drawn by catheter is acid, almost always clear and but 
slightly colored. During the first four or five days it is more or less cloudy 
from the presence of epithelial cells from the urinary passage, and uric 
acid salts. The specific gravity averages about 1012. The sediment always 
contains normal epithelial cells, various forms of uric acid crystals, and 
now and then hyaline casts. The amount of urine is small (Morse). This 
is due in part only to the insufficient supply of milk, as the amount is also 
small in bottle-fed infants. It increases rather rapidly about the fourth 
day, 20 to 50 cubic centimeters being passed in the first three days, and 
about 100 cubic centimeters on the fourth day. In the second week it 
averages between 200 and 300 cubic centimeters. 

The proportion of water eliminated in the urine to that taken in the 
food is greater after the fourth day, averaging 22 per cent, to 25 per cent, 
before, and 50 per cent, to 60 per cent, after. 

The urine of breast-fed babies almost never contains indican, that of 
the artificially fed baby usually but slight traces. Urobilin is never pres- 
ent in that of the breast-fed, seldom in that of the artificially fed. It does 
not contain albumin, and sugar is absent with the ordinary reagents. The 
sediment is slight, and consists entirely of cells. One-third to one-half 
gram of urea per kilo of body weight is said to be passed in twenty-four 
hours. Figures are of but little use, however, as the amount of urea varies 
with the character of the food. It is pretty certain, nevertheless, that 
from 40 to 50 per cent, of the nitrogen ingested appears in the urine. 
The amount of urine is relatively large. It varies between 200 and 500 

(917) 



918 MISCELLANEOUS. 

cubic centimeters from one to six months, and between 250 and 600 cubic 
centimeters up to 2 years. 

The urine of the new-born is rich in sodium chloride, which salt 
diminishes with age. During the first and second months of life it is in 
the same proportion as in adults. From the third to the fifth year, com- 
puted by kilogram weight, the amount is 0.57 gram; at 11 years, 0.44 
gram, and at 1G years, 0.18 gram. 

Phosphoric acid is seldom found, but when met with it is always in 
very minute quantity. 

Uric acid is present in the earliest urine, and the quantity regularly 
increases up to the third day, when it rapidly diminishes. 

On examining the kidneys of a new-born, the papilla? will be found 
filled with a reddish substance which obstructs the urinary ducts; this, 
as is well known, is nothing more than uric acid infarction and has no 
pathological significance. 

Parrot and Bobin found urate of soda, sulphate of calcium, mag- 
nesium, potassium, benzoic acid, allantoidin. and mucin, and Cruse denies 
the presence of sugar, oxalate of calcium, or hippuric acid. Creatinine 
and indican are not found in the urine of the new-born or wet-nursed. 
Xanthine is relatively abundant in cases of nephritis. 

In infantile atrophy, as may be presumed, the quantity of urine is 
far below the normal; it is yellow, acid reaction, often contains organic 
deposits, sugar, albumin and an excess of urea and phosphates. 

In icterus neonatorum the urine is pale-yellow, and contains urates, 
epithelial cells, and yellow masses of pigment. 

The urine of infants with scleroderma is reddish, acid with uratic 
deposits, and slight excess of urea. 

Albumix. 

The presence of albumin is always of importance, although not always 
due to an inflammatory process of the kidneys. It is often the sign of a 
simple congestion in athrepsia, cholera infantum, general or intestinal 
tuberculosis, intestinal catarrh, typhoid and scarlet fever. 

"A small amount of albumin in the form of nucleo-albumin is almost 
constantly present in the urine during the first four days of life. Tt often 
persists for two weeks, and not infrequently for two months. There is 
much difference of opinion as to the cause of this albuminuria. It has 
been attributed to the changes in the circulation at birth, to hyperaemia 
resulting from the changes in the metabolism after birth, to renal disease 
in the mother, and to irritation from uric acid. It is doubtful if any of 
these explanations are correct. The latest investigations show that albu- 
minuria is no more common in the children of women suffering from 
nephritis or eclampsia than in others. If uric acid is the cause, its action 



THE URINE. 919 

is probably as a chemic rather than as a mechanic irritant. Many observ- 
ers regard this albuminuria as physiologic. It is hardly safe to consider 
it so, however, until more is known about metabolism, the changes due to 
nourishment, and disturbances of nutrition in the new-born. Whatever 
the cause, it is certainly not a serious condition, and ought not to be looked 
upon as the forerunner of chronic nephritis in later life." 

In older children the presence of albumin in the urine is always 
pathological, except when it is the physiological result of the administra- 
tion of certain drugs (tincture of iodine, etc.). 

A slight amount of albumin may be found in nephritic colic due to 
the stimulus which the uric acid exerts upon the renal parenchyma. At 
other times, when present, there is an actual inflammation of the kidneys, 
as in scarlatina and diphtheria; there may be an amyloid degeneration 
without its being possible to discover any albumin in the urine. 

Sometimes children will be found pale, the urine perhaps abundant 
or diminished in quantity; it will contain albumin, a few hyaline casts, 
uric acid and epithelium, yet they will have good appetite, will play and 
appear otherwise quite well. Others become languid, lose their appetite, 
complain of headaches, painful micturition, and will pass a turbid and 
sedimentous urine. In these cases albumin soon appears. 

The more severe cases surfer from anuria ; partial oedema will occur 
in the eyelids, on the dorsum of the foot, etc. The next day the amount 
of urine will have been 50 to 100 grams in twenty-four hours. This will 
increase, perhaps, never to return to the normal. 

The color of the urine in Bright's disease will be variable, according 
to the amount of blood which it may contain, of acid reaction, and average 
specific gravity of 1010 to 1015. Under the microscope we find red and 
white corpuscles, haematin, renal epithelium, hyaline or granular casts, 
uric acid crystals, fat globules, and detritus. 

Chronic nephritis may be the result of an acute affection complicating 
scarlet fever. In these cases children suffer but little and seldom show 
more than a few cedematous spots. 

These forms of kidney involvement are rather rare, and cases which 
have been diagnosed as such have, on autopsy, proven to have been cases 
of amyloid degeneration due to syphilis, malaria, rachitis, struma, or 
tuberculosis. 

In the mild forms of diphtheria the urine suffers no change what- 
ever, but in the general infection, even in the early stages, albuminuria is 
found, which is a fairly positive evidence of systemic infection. If 
the urine diminishes in quantity and blood corpuscles are found under 
the microscope we may feel sure that the diphtheritic process has invaded 
the kidney, or else that a nephritis complicates the diphtheria. 

"In rachitis, albuminuria is comparatively rare; the quantity does not 



920 



MISCELLANEOUS. 




change materially, but the calcium salts have been found in marked dimin- 
ution. Marchand and Lehman have discovered lactic acid present. The 
phosphates and chlorides are in very small quantities. The urine of leu- 
kemic patients at times contains albumin and many lymph corpuscles as 
well as hyaline casts. The uric acid and hypoxanthine are in greater 
quantity. 

"Diabetes mellitus has been met with at a very tender age. 
"In a case of pseudo-hypertrophic paralysis Dennen reports marked 
glycosuria. 

•'Hamioglobinuria is found in "VYinckeFs disease, and the same as in 
adults, in malaria, syphilis, and as a result of exposure to cold. 

"Hematuria and pyuria have no 
special significance beyond that which 
they have in adults. 

"Uric acid is in excess during the first 
week and is a physiological phenomenon ; 
later on. deposits of urates and uric acid 
appear in the course of serious diseases of 
the digestive apparatus. Under other 
circumstances, the oxidation of nitrogen- 
ous substances being diminished (by dis- 
- of the respiratory or central nervous 
m). deposits of oxalate of calcium 
occur. 

"Infarcts of uric acid may be found 
even up to the seventh or eighth week. 
Children will strain, make repeated ef- 
fort- and cry out during urination; the 
diapers will be found stained with a 
darker urine than usual ; the edges of the 
wet surface will be seen reddened by a 
yellowish-pink sandy deposit. A careful 
analysis of this urine regularly shows an 
excess of uric acid, many epithelial cells, 
a few pus corpuscles, and mucus and traces of albumin. Quite frequently 
the urine is so acid as to produce such pronounced evidences of pain on the 
part of the infant as are met with in the nephritic colic of adults. 

"When tubercle bacilli are present in urinary sediment, the diagnosis of 
tuberculosis of the kidneys, ureters, or bladder may be positively made. 
Care should be exercised not to confound the tubercle bacillus with the 
smegma bacillus, which may often be present in the same specimen of 
urine and which stains like the former, though it decolorizes differently. 
1 It can be procured at Eimer & Amend., chemists' supplies, New York City. 




(*) (I) 

Fig. 301. — Urino-Pyknometer. 1 
for estimating the specific gravity 
of small volumes of urine. 



THE URINE. 921 

"The epithelium found in urinary sediments is often of great import- 
ance in determining- in what part of the genito-urinary tract the lesion 
exists, and a knowledge of the histology of these organs will sometimes 
prove invaluable. 

"The presence of echinococcus, filaria, etc., determines the exact nature 
in those diseases. 

"Dysuria is not always a manifestation of renal or vesical disease, since 
a high fever may at times originate it. In such cases children complain or 
cry out on attempting to urinate. 

"This symptom belongs as well to affections of the external genitals 
such as phimosis, urethritis, congenital anomalies of the urethra, those of 
the labia minora in females, etc." 

Specific Gravity. — The specific gravity of the urine is best taken with 
a hydrometer. If the urine is very scanty an instrument called the urlno- 
pyknometer, devised by Dr. Saxe, should be used. It has the advantage of 
giving the specific gravity when only 1 drachm or 3 cubic centimeters can 
be procured. 

Test for Albumin. 

Place in a test-tube about half a teaspoonful of pure water, in which 
dissolve one of the potassio-mercuric iodide tablets and one of the citric 
acid tablets. To this solution gradually add, drop by drop, the urine. If 
a gelatinous precipitate occurs, it may consist of albumin, an alkaloid 
such as quinine, or peptone. To determine which of these three sub- 
stances was originally present in the urine, heat the contents of the tube 
to the boiling point and note if the precipitate is redissolved. If such be 
the case, the precipitation was due to peptone and not albumin, as the 
latter would be coagulated and would not be dissolved. If the precipitate 
consists of a compound of the reagent with an alkaloid, it will be dis- 
solved completely upon the addition of alcohol, a result which would not 
occur if the precipitate consisted of albumin. The potassio-mercuric. iodide 
test is exceedingly sensitive, and whenever the results are negative, no 
precipitate occurring upon the addition of the urine, it is positive evidence 
of the absence not only of albumin, but of peptone and alkaloids as well. 
It is only in such cases where a precipitate occurs that it becomes necessary 
to apply alcohol and heat tests to determine the character of the precipi- 
tate. 

Directions for Use. — In testing urine for albumin with nitric acid, fill 
the large tube of the horismascope two-thirds full of the urine, which must 
be made perfectly clear and transparent, if necessary by filtration. Then 
pour into the funnel tube 25 or 30 minims of nitric acid, which will pass 
down through the capillary tube and form a layer underlying the urine. 



922 



MISCELLANEOUS. 



If albumin is present, a distinct white zone will presently appear at the 
point of contact, sharply defined against the black background, the amount 
of albumin being indicated by the density of the opaque ring. Sometimes 
air will remain in the capillary tube of the instrument, preventing the acid 
from running down the tube. It is always best to see that the tube is free 
from air before pouring in the acid. If air is present, it can generally be 
driven out by merely tilting the instrument or it may be driven down the 
tube by placing the thumb or middle finger on top of the funnel so as to 
cover it completely and pressing quickly and forcibly so as to cause a few 
bubbles of air to pass through the urine. 

In the use of the horismascope in 
applying the nitric-acid test for albu- 
min, these advantages are secured: 

1. The acid when it comes in con- 
tact with the urine is of full strength, 
rendering the test much more delicate 
than as ordinarily applied. 

2. The reaction is not liable to be 
obscured by separation of uric acid or 
acid urates, such separation not taking 
place in the horismascope until after 
a considerable interval. 

3. The black and white back- 
grounds of the instrument render much 
more distinct the effects produced by 
the reagent. 

4. Xo especial skill is required on 
the part of the operator. 

The faintest visible trace of al- 
bumin as shown by the nitric acid 
test may be stated to be V 60 per cent. 
One-fourth of 1 per cent, is just suffi- 
cient to make the albumin layer opaque when viewed from above. If larger 
amounts are present the percentage may be approximately estimated by 
diluting the urine until the opacity is reduced to that corresponding with 
0.25 per cent. 

There are many other tests which can be advantageously made by 
introducing the reagent from beneath, allowing it thus to form a distinct 
stratum underlying the fluid to be tested. 

In testing a specimen of urine it is always best to first determine its 
reaction. For this purpose red and blue litmus paper should always be at 
hand. A small piece of each kind of paper should be added to the specimen 
and the result be observed. If the urine is alkaline the red litmus paper 




Fig. 302.— The Horismascope or Albumo- 
seope. A new instrument for determining the 
presence and amount of albumin in theurine. 
Xo liability of the acid mixing with the urine. 
The slightest visible trace of albumin can be in- 
stantly detected against the dark background. 
Color reactions due to urinary and biliary pig- 
ments are clearly shown against the white 
background. 



THE URINE. 923 

will turn blue, and if it is acid the blue litmus paper will turn red. It is 
very important that when testing for sugar the urine should be slightly 
alkaline, and when testing for albumin it should be slightly acid. In order 
to render the specimen slightly alkaline or slightly acid according to the 
test that is to be applied, sodium carbonate tablets and citric acid tablets 
should be used. 

Robert's Albumin Test. 

IJ Sat. sol. magnes. sulph. (c. p.) 5 ounces 

Nitric acid (c. p.) 1 ounce 

This test is a cold one, viz. : put about 1 cubic centimeter of solution 
into medium-sized test-tube — incline on a steady rest on an angle of 45 
degrees. With a slender pipette allow the filtered urine to be tested — to 
flow very slowly down the side of the tube. It will float above test solution. 
Use about 1 cubic centimeter of urine. Examine in front of the window 
by daylight, with aid of black background. A sharp clear-cut, white line 
will appear at contact line if albumin is present. A wide band of white 
is not always indicative of albumin, neither is a narrow zone above in the 
urine, which may be due to mucus. The sharp, clear-cut zone is distinctive. 

A New Test for Albumin. 1 — This new and simple test is based upon the 
following facts: — 

1. Albumin is coagulated by carbolic acid. 

2. Equal volumes of non-albuminous urine and a mixture, composed 
of equal parts of carbolic acid and glycerine, form an emulsion which clears 
up entirely upon agitation, leaving a perfectly transparent and highly re- 
fractive liquid. 

3. Equal volumes of albuminous urine and the above mentioned carbol- 
glycerine solution, when mixed together, produce a white turbidity, which 
remain?, in spite of agitation, and does not precipitate on standing nor 
redissolve. 

The test is very sensitive, distinctly showing the presence of 0.1 per 
cent, of albumin in the urine, the degree of turbidity being proportionate 
to the percentage of albumin contained in the urine. 

Test. — Two cubic centimeters of carbol-glycerine solution are poured 
into a small test-tube, and 2 cubic centimeters of the filtered urine are 
added. Mix thoroughly with a glass rod. or agitate. If a clear, transparent 
liquid results, there is no albumin present ; but if the slightest turbidity is 
noticeable the urine is albuminous. 

The Diazo Reaction in Urine. — The diazo test was suggested by 
Ehrlich, in 1882, as a valuable diagnostic measure in tj^phoid fever, al- 
though he admitted the occurrence of this reaction in a few other con- 
ditions shortly to be considered. 



1 Fuhs. Medical Record. March 8, 1902. 



924 MISCELLANEOUS. 

The diazo reaction depends upon the fact that if sulphanilic acid 
(amidosulphobenzol) be acted upon by HXO, diazosulphobenzol is formed, 
which unites with certain aromatic substances occasionally present in the 
urine to form aniline colors. 

Friedenwald has recently reviewed the literature of this reaction, 
and showed that many of the contradictory results obtained by some ob- 
servers are due to failure in carrying out Ehrlich's methods in performing 
the test, which is best accomplished as follows : — 

To obtain diazosulphobenzol in a perfectly fresh condition sulphanilic 
acid is kept in solution with hydrochloric acid : to this sodium nitrate is 
added, whereupon HXO is liberated and diazosulphobenzol is formed. 

Process. — Two solutions are prepared, as follows: — 

1. Two grams of sulphanilic acid. 50 cubic centimeters of hydrochloric 
acid. 1000 cubic centimeters of distilled water. 

2. A 0.5 per cent, solution of sodium nitrite. 

In performing the test. 50 parts of Xo. 1 and 1 part of Xo. 2 are 
mixed, and equal parts of this mixture and of the urine in a test-tube are 
rendered strongly alkaline with ammonia. If the reaction be positive the 
solution assumes a carmine-red color, which on shaking must also appear 
on the foam. Upon standing for twenty-four hours a greenish precipitate 
js formed. 

The test must not be considered positive unless a distinct red colora- 
tion extends to and includes the foam on shaking. 

Diazo Reaction in Nurslings and Children. — "The diazo reaction never 
appears in the urine of healthy nurslings. 

"High temperatures in children do not affect the reaction. 

"Catarrhal pneumonia (acute) and also chronic does not give the 
reaction. 

"Diphtheria and varicella do not give this reaction. 

"Otitis, coryza, lymph-adenitis, omphalitis, bronchial catarrh, pleu- 
ritis, gastro-intestinal catarrh, colitis, congenital syphilis, eczema, and 
erythema give no reaction. 

"Erysipelas and morbilli almost always give this reaction. 

"The severer the attack of erysipelas or measles, the more pronounced 
the reaction, and when intensity of the disease vanishes the reaction looses 
its strength. In lethal cases the reaction remains until death is plainlv 
pronounced. Therefore the intensify of the disease and the reaction go 
hand in hand. 

"The reaction can be found in the urine of nursling one or two davs 
before exitus, no matter what the nature of the disease. 

"The prognosis can at times be guided by the intensity of the reac- 
tion, for the more severe the disease the greater the reaction. 

"The reaction is most commonly found in typhoid fever from the 



THE URINE. 925 

i'ourth to the seventh day and thereafter, and if the reaction be absent the 
diagnosis is doubtful. 

"Cases of typhoid fever characterized by faint reaction and occur- 
ring only for a short time may be predicted to be of very mild type. 

"The reaction is occasionally noted in phthisis pulmonalis, but only 
in cases pursuing a rapid course toward a fatal termination. 

"The reaction is sometimes, but not often, observed in cases of measle>. 
miliary tuberculosis, pyaemia, scarlet fever, and erysipelas. 

"In diseases unaccompanied by fever, as chlorosis, hydraemia, dia- 
betes, diseases of the brain, spinal cord, liver, and kidneys, the reaction is 
always absent." 

The weight of clinical evidence strongly confirms all of Ehrlielrs 
original claims for this reaction, but more especially so with regard to 
typhoid fever and pulmonary tuberculosis: if present in the latter disease 
any length of time, the prognosis is very unfavorable. 



IXDICAX. 

Detection of Indican. — JaflVs method consists in mixing 10 cubic cen- 
timeters of strong hydrochloric acid with an equal volume of urine in a 
test-tube, and. while shaking, add drop by drop a perfectly fresh, saturated 
solution of chloride of lime, or chlorine water, until the deepest obtainable 
blue color is reached. The mixture may next be titrated with chloroform. 
which readily takes up the indican and holds it in solution, and the quan- 
tity present may be approximately estimated according to the depth of 
the color. If the urine contains albumin it should be removed before 
applying this test, otherwise the blue color . often arising from the mixture 
of hydrochloric acid and albumin after standing, may prove misleading. 

Test for Sugab (Glucose) in Urine. 

The best test for sugar is furnished by the indigo and sodium car- 
bonate tablets. This test is applied by first placing in a test-tube about 
half a teaspoonful of water, one of the indigo and sodium carbonate tab- 
lets, and one of the sodium carbonate tablets. Heat the contents of the 
tube gently until solution is effected, and then add 1 drop of the urine to 
be tested, 'keeping the fluid at the boiling point without allowing it to boil. 
If no effect is produced add a second drop of the urine and heat as before. 
If no change of color results add another drop of the specimen, and so on 
until at least five drops have been added. If any notable amount of sugar 
is present, one or at least two drops will suffice to bring about the reaction. 
The fluid will change from pure blue to amethyst, then to purple and red. 
finally fading to a pale yellow. If the quantity of sugar is very small, the 



926 



MISCELLANEOUS. 



color will change only to a purple or red, and in nearly every case five drops 
of normal urine will produce this change. 

If one drop of the urine produces, a strong reaction, dilute the urine 
to one-half, one-quarter, one-eighth, etc., in succession until a single drop 
ceases to produce a visible change, and estimate roughly in this manner 
the quantity of sugar present. While observing the various changes of 
color which the liquid undergoes, if sugar is present, any agitation of the 
solution should be carefully avoided. The reason for this precaution is 
readily explained by the fact that the original blue color of the solution 
may be restored by simply shaking the liquid. This remarkable effect is 
not due to cooling, but to the oxidizing influence of the air. 

In regard to the comparative value of tests for sugar, it may be said 
that the copper test is the least trustworthy. Among the normal constit- 
uents of the urine, uric acid is capable of reducing copper compounds, and 
numerous substances which may accidentally be present have a similar 
action. The indigo test is capable of detecting a smaller quantity oi sugar 
in the urine than any other reagent. One drop of a solution of glucose, 
containing a half grain to the fluidounce, shows a distinct reaction. 

Whitney's Test (for Sugar). 1 — The following table will give the 
amount of sugar in analytical testing: — 



Table No. 106. 



If Reduced by 


It Contains to the Ounce 


Percentage. 


1 minim 


16.0 grains or more 


3.33 


2 minims 


8.0 grains 


1.67 


3 


5.33 " 


1.11 


4 " 


4.0 


0.83 


5 


3.20 " 


0.67 


6 " 


2.67 " 


0.56 


7 


2.29 " 


0.48 


8 


2.0 


0.42 


9 


1.78 gram 


0.37 


10 


1.60 " 


. 0.33 



The Method of Procedure. — Heat 1 drachm of the reagent in a test- 
tube to boiling; add the urine slowly, drop by drop, until the blue color 
begins to fade; then more slowly, boiling three to five seconds after each 
drop, until the reagent be perfectly colorless, like water, or until 10 drops 
only are added. 

It will be noted after reduction that the reagent, on cooling, resumes 
the blue color again. This change is due to the absorption of oxygen from 
the atmosphere, changing the reduced suboxide held in solution to the blue 



'•Physicans can procure the reagent, accurately compounded as described, from 
the Lewis Chemical Company. 



THE URINE. 927 

protoxide again. This should not be mistaken for imperfect reduction or 
defect in the reagent. The change takes place quickly by shaking the tube, 
and the reduction can be repeated, if done immediately, before the evapo- 
ration of the ammonia by the addition of the saccharine urine as before, 
though not with the same degree of accuracy. 

When a specimen of saccharine urine contains a large amount of albu- 
min, the reduction takes place without interference by the albumin present, 
but leaves the reagent more or less of a yellow tint, according to the 
amount. A large amount of coloring matter has a similar effect, but there 
is little danger of uncertainty when not more than ten minims are used. 

Fermentation Test. — With the aid of a saccharometer we have a con- 
venient method of estimating the quantity of sugar in the urine. A piece 
of yeast-cake about the size of a pea is added to a test-tube of urine, and 
allowed to stand at a temperature of 90° F. If sugar is present, yeast 
transforms it into alcohol and carbon dioxide, by fermentation. While this 
test is reliable, it is not a very delicate one. 



CHAPTER V. 
BACTERIOLOGICAL MEMORANDA. 1 

Demonstration of Tubercle Bacilli in Sputum. 

vTith a forceps pick out a thick, purulent portion of the sputum. 
Make a thin spread between a slide and a cover-glass. Allow this to dry 
thoroughly in the air or it can be dried by holding it several inches above 
a Bunsen burner. Stain with several drops of ZiehTs solution and heat 
it over a Bunsen burner: — 

ZiehFs solution : — 

B FaehaiB 1 gram 

Alcohol 10 grams 

Carbolic acid 5 grams 

Water 100 grams 

After heating wash the cover-glass in water, aud lastly add several 
drops of Gabbet-Ernst solution : — 

R Methylene blue 2 grams 

Diluted sulphuric acid <2o per cent.) 100 grams 

Rinse this solution off the cover-glass, dry between filter paper, and 
mount with Canada balsam. 

I'nder the immersion lens the tubercle bacilli will be stained red, and 
all other bacteria will have the blue background. 

Aqueous Solutions. — Aqueous solutions of methyl violet, gentian vio- 
let, fuchsin. and the other aniline dyes are prepared by adding 1 cubic cen- 
timeter of the saturated alcoholic solutions of the desired dye to 20 cubic 
centimeters of distilled water. This will impart a decided color to the 
liquid so that a pipette full will be barely transparent. 

The true aqueous solutions are made by dissolving the dyes in water. 
but these are weak and not so effective as those prepared from the alcoholic 
solutions. These solutions deteriorate in a -hort time. The carbol-fuchsin 
and alkaline methylene blue will keep a little longer.. but they require to 
be filtered occasionallv. 



ir The reader is referred to works on bacteriology i such as Lenh&rtz-Brooks) 

for blood examinations in malaria, anaemia, leukaemia, and for the YVidal reaction 
of the blood in tvphoid fever. 

128) " 



BACTERIOLOGICAL MEMORANDA. 929 



Gonococcus. 

With a platinum loop pick out a thick purulent portion of the discharge. 
Make a thin spread between two slides. Dry in the air or over a Bunsen 
burner. Stain with methylene blue for half a minute. Rinse this solu- 
tion off the slide. Dry between filter paper and mount with Canada balsam. 

Diplococcus Pneumonia. 

With a platinum loop pick out a thick portion of the sputum. Make 
a thin spread between two cover-glasses. Immerse in a watch-glass of ani- 
line gentian violet for ten minutes. Pass through water, and place in 
Gram's iodine solution for five minutes. Wash in alcohol until no fur- 
ther color comes away. Place on edge to dry. Mount in Canada balsam. 

Klebs-Loeffler Bacillus. 

Bacteriological method of diagnosis is given in detail in chapter on 
"Diphtheria." Bacillus stains well with Loefner's alkaline methylene blue. 

Streptococcus. 

Usually found in purulent ear, eye, or nasal discharges, sometimes in 
vaginitis. 

With a platinum loop pick out a thick portion of the discharge. Make 
a thin spread between two slides. Dry in the air or over a Bunsen burner. 
Stain with methylene blue or fuchsin solution. Mount in Canada balsam. 

Meningococcus. 

Lumbar puncture fluid in cerebro-spinal meningitis should be spread 
between two cover-glasses and dried over a Bunsen burner. Stain with 
methylene blue. Mount in Canada balsam. 



CHAPTER VI. 

ANESTHETICS IN CHILDREN. 

Nitrous Oxide and Ether. 

The ideal anaesthetic for children is a combination of nitrons oxide 
and ether. Whenever it is possible one skilled in its administration sliouhi 
he employed. The responsibility of attending to a major or minor opera- 
tion is so great that unless one skilled in the administration of an anti- 
thetic is employed there may be serious after-effects. To properly guard 
the heart and respiration requires experience, and no surgeon should un- 
dertake to do both, excepting in extreme emergencies. 




Fig. 303. — Gas and Ether Inhaler. 



Walter K.. 5 years old. Mas given a mixture of nitrous oxide and ether by Dr. 
Culler. The child was anaesthetized without a struggle. I removed the adenoids 
and hypertrophied tonsils. The child showed no evidence of shock. There was 
slight nausea. No other evidence of gastric disturbance. There were no after- 
effects. 



Chloroform. 

Chloroform yapor is decomposed into chlorine and hydrochloric acid 
by the presence of the common gas flame, and may thus give rise to irri- 
tating effects upon the respiratory organs. 
(930) 



ANAESTHETICS. 931 

When employed it should be administered by the drop method. By 
ibis method, combined with fresh air, the danger is minimized. The statis- 
tics of Dr. George Gould, of Philadelphia, and the Lancet Commissioner, 
prove that chloroform anaesthesia causes more deaths than ether as an 
anaesthetic. 

Ethyl Chloride. 

This is an excellent anaesthetic and can be administered as a spray on 
a chloroform mask. I have frequently used it in my hospital service to 
remove adenoids, tonsils, and for a circumcision. Ethyl chloride is a rapid 
and safe anaesthetic. 

Local Ancesthesia. — Ethyl chloride, as a spray until the part is frozen, 
is sufficient to open an abscess, for a lumbar puncture, or even an empyema, 
in a sensitive child, or where general anaesthesia is contraindicated. 

Ether. 

Sulphuric ether, used alone as an anaesthetic in children, may be 
considered. It requires a much longer time to produce its effect, 
although it has no depressing effect upon the heart. Statistics show that 
in 300,175 administrations of ether there were 18 deaths. Out of 638,461 
of chloroform, there were 160 deaths, showing the following ratio: — 

Chloroform mortality . 1 to 3,749 

Ether mortality 1 to 16,675 

We therefore see that ether is by far the safer anaesthetic. Weir states 
that "ether narcosis is safer, even though the kidneys are slightly affected." 
Ether is frequently combined with oxygen, and, as previously stated, with 
laughing gas, and forms in the latter combination the safest anaesthetic for 
children. 

Regarding the Effect of Ether in Affections of the Air Passages. — 
Affections of the air passages following ether narcosis are usually the result 
of aspiration of infected mouth contents. Ether causes a slight increase of 
mucous secretion. It has no irritant action on the tracheal or bronchial 
mucous membrane. When bronchitis or pneumonia exists, greater care 
must be taken owing to the increased secretion produced by the ether, as 
stated above. When nitrous oxide is given we avoid the irritant effect just 
described. 

In adenoid operations, give nitrous oxide until cyanosis is seen, then 
give ether; the change relieves cyanosis at once. 

Lymphatic Enlargement in Children. — Most deaths occur in children 
in which the lymphatic condition exists — the so-called lymphatic diathesis. 

The Children's Clinic at Graz, during the last twenty years, shows 
that records of fatalities with chloroform always revealed the lymphatic 



932 MISCELLANEOUS. 

hyperplasia, which is the principal feature of the so-called constitutio lym- 
phatica. (Bead chapter on "Status Lymphaticus") 

Ewing believes the above conditions prevail in America. Lartigan's 
report of the Koosevelt Hospital shows that death came after ether as well 
as after chloroform, in children affected by the lymphatic constitution. 

The presence of universal enlargement of the lymph nodes without 
direct inflammatory cause, hypertrophied tonsils, adenoid hyperplasia, 
tendencies to anaemia, weakness of pulse, irregular heart's action, along 
with insufficient development of the heart and large blood-vessels, show 
that the lymphatic condition exists. 

Local Anesthesia by the Injection of Sterile Water. 1 

When the heart, lungs, or kidneys contraindicate the use of a general 
anaesthetic, then local anaesthesia should be tried. Gant advises the use of 
regional injections of sterile water in the part to be incised. He claims 
that an abscess can be opened or similar surgical work performed without 
pain by this means. It is well worth trying. 

Intra-spinal Anesthesia. 2 

Corning, of New York, about twenty years ago found that anaesthesia 
could be produced in the lower part of the body by injecting cocaine in the 
lumbar region of the spine. The patient is placed in a sitting position 
well bent forward, aud firmly held during the injection. The skin should 
be cleaned in the usual antiseptic way, followed by an ethyl chloride spray. 
This renders the introduction of the needle practically painless. A point 
one-half inch to either side of the median line and midway between the 
spinous processes is taken, and the needle pushed forward, inward, and 
upward. Special effort is made to keep away from the central part of 
the spinal canal by a close relation of the needle point to the dura. The 
instrument used is of the simplest kind. A small-sized, steel aspirating 
needle with a short-beveled pointed end. having a well-fitted hypodermic 
barrel, answers every purpose. As nearly as possible the same amount of 
cerebro-spinal fluid is allowed to escape as of the injection medium which 
is to be introduced. The injection is given slowly, usually taking one and 
one-half to two and one-half minutes. Often the first evidence that the 
cocaine is taking effect is some dilatation of the pupils or a slight nausea. 

This method has been especially valuable where circumcision is to be 
performed, or where the examination of the bladder is to be made. In 

1 For details of this method, see article of G ant's, published in the New York 
Medical Journal, January 23, 1904. 

2 The technique of lumbar puncture is described in article on "Meningitis" 
(page 827). 



ANAESTHETICS. 933 

children I have frequently found considerable nausea and vomiting fol- 
lowing the use of cocaine ; the same is also true of eucaine. The analgesic 
elfect of eucaine is in some cases as good as that of cocaine. 

Dose Required. — Five, rarely ten minims of freshly prepared 2 per 
cent, cocaine solution are required. The solution should be freshly pre- 
pared for each case, by dissolving the eucaine or cocaine in sterile water. 
It is well to remember that there are certain toxic effects noted in some 
children. This should be borne in mind, and individual idiosyncrasies 
noted. 



CHAPTEE VII. 
DISINFECTION. 

We know that pathogenic bacteria abound in the false membrane, in 
the sputa, and in the secretions of the diseased mucous membrane, and 
also in the stools and urine. Physicians and nurses are particularly ex- 
posed to the danger of infection when examining or swabbing the throats 
of patients, through the coughing of mucus or particles of membrane into 
their faces. Bacilli frequently abound in the form of dust. They can with- 
stand drying fourteen days. They may retain their virulence four to seven 
months, in dark, damp, and cold places. 

Disinfections to be Used as Means of Prevention. — As a means of 
prevention the following may be recommended : — 

Corrosive sublimate 1 to 10,000 

Cyanide of mercury 1 to 10,000 

Chloroform water. 1 

2 per cent, carbolic acid in 30 per cent, alcohol. 

Turpentine and alcohol equal parts with 2 per cent, carbolic acid added. 

The above solutions are to be used to prevent the development of the 
bacilli on the adjacent mucous membrane. Great care should be taken 
in using poisonous solutions in the treatment of children. 

Paraform is extensively used and recommended. 

Clinical thermometers and all instruments should be disinfected in 
carbolic acid solution immediately after being used. The nurse or at- 
tendant on the patient should observe the same precautions as the phy- 
sician, who, after handling the patient or touching anything about him, 
should disinfect his hands in a basin of 3 per cent, carbolic solution, which 
together with a nail-brush should be kept constantly on hand in the sick 
room. When practicable, a room at the top of the house should be chosen 
in which to place the patient. All superfluous objects, curtains, carpets, 
ornaments, etc., which are liable to catch dust should be removed, only 
articles necessary for the patient's comfort being left in the room. Good 
ventilation must be maintained. A sheet kept constantly moistened with 
carbolic acid solution should be tacked in the doorway, making it necessary 
to push it to one side in going in and out of the room, thus making the 



1 Chloroform water is made by saturating a pint of water with a drachm or 2 of 
pure chloroform and pouring off, after several vigorous shakings, so that none of the 
chloroform passes over. 
(934) 



DISINFECTION. 935 

isolation more perfect. All children belonging to a family in which an 
infectious disease has occurred should be prevented from attending school 
for a shorter or longer period, never less than four weeks. 

The presence of injects in the sick room, especially flies, should be 
guarded against as much as possible, in view of the fact that they may 
act as carriers of the disease. Xo food should be allowed to stand uncov- 
ered in the sick room, as in certain cases pathogenic organisms may gain 
access and multiply therein. 

Sputa are best disinfected by steam sterilization, together with the 
sputum cups. The addition of 15 grams of sal-soda to a liter of water 
materially aids the process of cleaning. 

Urine and faces are best treated together by means of milk of lime 
In this we possess the most valuable agent for the disinfection of 
typhoid and cholera stools. This agent is prepared as follows : To un- 
slaked lime, placed in a jar, as much water as it will absorb is added. 
The unslaked lime is stirred up with 4 parts of water to form the milk of 
lime, and this is mixed intimately with the discharges until the mixture 
gives a strong alkaline reaction (tested by litmus paper). 

Chloride of lime, to be effective, must contain 25 per cent, of available 
chlorine. Six ounces to the gallon of water represents the standard solu- 
tion. 

Carbolic acid, unless in combination with sulphuric, and corrosive 
sublimate are not suitable for the disinfection of stools. 

Discharges can also be disposed of by burning after being mixed with 
sawdust. 

Water-closets are best disinfected bv chloride of lime solution. 



CHAPTER VIII. 

THE ADMINISTRATION OF DRUGS TO CHILDREN. 

A few points concerning the use of drugs in children should be 
noted : — 

1. Give the minimum dose of a drug in the beginning of a disease. 

2. Administer the drug in a palatable form. 

3. The soluble tablet triturates should be administered, as they com- 
bine a minimum quantity with solubility and palatability. 

4. Remember the idiosyncrasies of drugs and guard against toxic doses 
by watching the effect of a drug in any given case. 

5. In some specific diseases such as diphtheria, give a sufficient quan- 
tity of antitoxin to obtain a therapeutic result. 

6. Certain drugs, for example, belladonna, calomel, quinine, strych- 
nia, bromoform, and alcohol, when cautiously administered can be given 
in very large doses. It is only necessary to note the physiological effect 
and then to give the drug until its point of tolerance is reached. 

Accuracy in dealing with poisons is very important in children. It 
is surprising to see the difference in size of various teaspoons on the market. 
I advise using a medicine glass, which is graduated with teaspoon, etc. 



(936) 



CHAPTER IX. 

LOCAL REMEDIES. 

Cold Compresses. 

Cold compresses may be made out of linen or cheese-cloth folded sev- 
eral times and wrung out in ice-water. If there is any abrasion of the 
skin, 1 part of glycerine should be added to every 5 parts of water. If con- 
stant cold is wanted, compresses should be changed frequently. 

Hot Compresses or Fomentations. 

Hot compresses or fomentations are made by wringing out a piece 
of flannel in hot water. As this is oftentimes hotter than the hands 
can stand, the flannel may be placed in a towel, two ends being kept from 
the water and then wrung out in the towel by twisting the ends. In apply- 
ing fomentations they should not be hotter than can be borne by the face 
of the mother or nurse. To retain the heat they may be covered with oil 
silk, oil paper, or oiled muslin, and then with a dry towel. Eenew when 
cool. 

Poultices. 

A poultice is intended to supply heat for a greater period than a 
fomentation. It should not be more than one-half inch in thickness. 

A flaxseed poultice is made as follows: A sufficient quantity of 
water is heated, and when brought almost to the boiling point, the flaxseed 
meal should be added slowly, stirring all the while to avoid lumping. 
The meal may be added until it has the consistency of hot mush, 
too thick to flow. This may be spread on a piece of linen or cotton 
cloth, the edges turned over slightly and the part to which it is to be 
applied next to the body must be covered with an old handkerchief or 
thin piece of linen. See that it is not hot enough to burn the skin. 
The poultice should be larger than the affected area. Afterward cover 
with oil silk or paper to keep out the air, and then bandage in place. This 
can be renewed every hour or so. Have everything ready when the poul- 
tice is made, as it quickly cools when exposed to the air. 

Turpentine Stupes. 

Turpentine stupes are found very useful in cases of abdominal pain. 
A piece of flannel is wrung out in hot water, the same as in a fomentation, 

(937) 



938 MISCELLANEOUS. 

except a little soap or oil added to the water. A little turpentine should 
then he sprinkled evenly over the surface of the flannel, about 30 drops to 
each square foot or a teaspoonful may be added to the water. Apply the 
same as a fomentation. 

Mustard Plasters. 

Mustard plasters for infants should be made with 1 part of mustard 
to 3 or 4 parts of flour or flaxseed meal. Add warm water and stir until 
of the proper consistency. Spread thinly on a cloth and apply directly to 
the skin. It is to be kept on until the skin is reddened, not blistered. 

Ginger Poultice. 

Ginger poultice is made in the same way as that described for the 
making of mustard plasters, and has its advantages in that it will not 
blister. 

Cantharidal Collodiox. 

In using the cantharidal collodion care should be exercised to remove 
all moisture and excretions from the skin before applying, otherwise the 
cantharidin, being soluble in water, will not come into contact with the 
skin. One of the most convenient methods of preparing the skin for the 
application of cantharidal collodion is to wash the part with vinegar or 
dilute acetic acid. 

Venesection (Blood Letting). 

Local blood letting is frequently a valuable therapeutic aid, especially 
in meningitis and in cerebral pneumonia, in fact, wherever Bymptoms of 
cerebral hyperemia are noted. Convulsions are sometimes prevented by 
relieving congestion with the aid of a few leeches. Baginsky reports the 
value of venesection as a routine measure in certain types of diseases, such 
as continued convulsions, in which relief can be afforded by this means. 
The skill of the surgeon is necessary, for we must consider the possibility 
of infection while opening a vein. 

Dry Cuppixg. 

The application of dry cups is useful in marked dyspnoea. It is there- 
fore indicated in asthma, broncho-pneumonia, and in pulmonary oedema, 
two cups may be applied on each side posteriorly for several minutes. If 
relief is afforded, they can he applied once every twelve hours. 



CHAPTER X. 

RECTAL MEDICATION IN CHILDREN. 

When" the stomach is irritable in young children I prefer to medicate 
per rectum. The gastric mucous membrane will sometimes show an in- 
tolerance for drugs. It is advisable, especially in exhaustive diseases, such 
as diphtheria, typhoid fever, and the intestinal disorders, to support the 
strength of the body with nutrition. In such cases vomiting may be pro- 
voked by the administration of drugs. Children will frequently object to 
taking medicine, and it is painful to watch the struggle between mother 
and child while attempting to force the medicine into the infant's mouth. 
In such cases, especially in very young infants with whom we cannot reason, 
the rectum should be chosen as the proper channel for the introduction of 
the drug. The rectum absorbs slowly but surely. 

The following drugs may be given per rectum and the doses gradually 
increased : — 

Aconite may be given in suppository, but shows its action only in large 
doses. We must therefore administer it in repeated small doses to obtain 
its effect. For example, we may give 1 or 2 drops of the tincture in a 
suppository to a year-old child. 

Belladonna acts as an excellent sedative in cough, and exerts a very 
favorable influence on the muscle fiber of the intestine. We may use 1 / 6 
minim of extract of belladonna in twenty-four hours, divided into three 
or four suppositories, for every two years of age. 

Bromides should be given in doses of 3 grains for each year of life, in 
two suppositories; 3 / 4 grain if it is to be continued. In severe spasm we 
may give two grains for each year of life, in two suppositories rapidly fol- 
lowing each other; for example, in laryngismus stridulus. 

Caffeine is usually injected subcutaneously. It may, however, be 
administered in a suppository with equal parts of benzoate of sodium. 
For example, one and one-half grains to a suppository, using two daily 
for each year of the child's life. 

Digitalis. — Powdered digitalis is with difficulty absorbed by the rec- 
tum. The tincture should, therefore, be used. The maximum dose for 
each year of life is 4 drops, divided into two suppositories. 

Iodine and its preparations are exceptionally well borne by the rectum, 
and fully absorbed. Three grains for each year of life, in two supposi- 
tories, is the maximum dose; 3 / 4 grain if it is to be continued. 

(939) 



940 



MISCELLANEOUS. 



Mercury should only exceptionally be given per rectum, and then only 
in the form of calomel, 3 / 4 grain in a suppository for each year of life. 

Nux Vomica.— One-sixth of a grain for every two years, in three sup- 
positories. 

Strychnine should only be given to children over 10 years of age. 

Salicylic Acid. — Seven and three-quarter grains for each year of life, 
in divided doses (three or four). 

Quinine is best given in suppositories. The daily maximum dose is 
2 to 3 1 / 3 grains, in two suppositories, for each year of life. 

Antipyrine may be given in the same dose as quinine. 

Opium. — Pulvis opii may be given in suppositories, in doses of 1 / 06 
grain for each year of the child's age, and this dose may be repeated in 
severe cases every two hours. 

Toxic symptoms should be carefully watched for. and the use of the 
remedy discontinued on their appearance. These doses are small ones and 
may be increased. 






CHAPTER XI. 



PRESCRIPTIONS FOR VARIOUS DISEASES. 
The following prescriptions have served the author and are in use at 



one of his clinics in New York City 
Summer Diarrhcea. 

I£ Calomel tablets, 1 / 10 grain. 

One every two hours for a child 1 to 
2 years old. 

Followed by (next day) : — 

R- Bismuth betanaphthol, 5 grains. 
Every two hours in water. Or 

I£ Mist, ereta, 2 ounces. 
Teaspoonful every two hours. Or 

I£ Bismuthi subnit., 20 grains. 
Misturae cretse comp., 4 drachms. 
Aquae, q. s. ad 2 ounces. 
M. Teaspoonful every two hours. 



Gastroenteritis. 
1$, Castor oil. 

Teaspoonful every two hours for one 
day. 

If diarrhcea persists after flushing the 
colon and rectum and also washing the 
stomach, after using former remedies: — 
IJ Eudoxine, 5 grains. 

Every three hours. 

The diet is most important. 



Persistent Vomiting. 
Lavage (stomach washing) with table 
salt one teaspoonful to quart of warm 
water (100° F.). Then leave stomach 
rest for at least six hours. 



Mouth-wash. 
Pulv. acid, boric, solution (1 per cent.), 



Stomatitis or Aphthae. 
R. Solut. Kali Permangan. (1 per cent.). 
Dilute with equal parts of warm water. 
Wash three times a day. 



Tonic After Exhaustive Disease, 
Such as Pneumonia or Summer 
Diarrhcea. 
I£ Ferri pyrophos., 1 drachm. 
Quininae sulph., 1 / 2 drachm. 
Strych. sulph., % grain. 
Acid phosph. dil., 2 drachms. 
Aquae, q. s. ad 4 ounces. 
M. Teaspoonful three times a day. 



Tonic and Restorative. 
B Ferri et quiniae citrat., 1 / 2 drachm. 
Syrup hypophos. comp., 4 drachms. 
Aquae, q. s. ad 2 ounces. 
M. Teaspoonful after each meal. 



Tonic for Chorea. 
I£ Liq. potass, arsenitis, y 3 drachm. 
Ferri et ammon. citrat., 1 drachm. 
Aquae, q. s. ad 2 ounces. 
M. Teaspoonful three times a day. 
Increase gradually. 



Pertussis. 
R- Bromoform ( Merck ) , 1 drachm. 
Tinct. cardamom comp., 1 drachm. 
M. D. S.: Five drops in water three 
times a day for a child 1 year old. 

Add 1 drop for every two years, thus: 

6 drops for baby 3 years old 

7 drops for baby 5 years old 

Or: — 
R Fl. ext. belladonna, 10 drops. 

Mist, glycerrhiz. comp., q. s. ad. 2 ounces. 

M. D. S.: Teaspoonful every two 
hours for a child 2 to 4 years old; 
younger children V 2 the dose. 

(941) 



942 



MISCELLANEOUS. 



Or: — 

Apply ung. belladonna over surface of 
chest every second night. 

Capillary Bronchitis. 

When expectoration is viscid: — 
R. Amnion, carbonat., 10 grains. 
Syr. senega, 4 drachms. 
Syr. prun. virg., 6 drachms. 
Aquae camph., q. s. ad 2 ounces. 

M. D. S. : Teaspoonful every two hours 
with water. 



Acute Catarrhal Bronchitis. 

P* Amnion, muriat., 15 grains. 
Amnion, bromid., 20 grains. 
Syr. liquorit, drachms. 
Tinct. opii camph., 2 drachms. 
Aquae, q. s. ad 2 ounces. 

M. D. S.: One-half teaspoonful every 
two hours. 



Pleurisy. 
(Cough with pain, on breathing.) 
P* Pulv. Doveri, 10 grains. 

Pulv. ext. liquorit, 20 grains. 
Sacch. albi, 30 grains. 

M. ft. chart, no. 20. 
M. D. S.: One powder every three 
hours. 



Tubercular Cough. 

Py Creosote carbonate. 

Five drops in milk, soup or broth three 
tunes a day, for a child 2 years old. 



Persistent Diarriicea, with Tuber- 
cular Symptoms. 

P* Guiacol carbonate, 3 to 5 grains. 
For a child 1 year old. 



Entero-colitis. 

P* Tinct. kino, 20 minims. 

Misturae cretae comp., 1 drachm. 
Aquae, q. s. ad 2 ounces. 

M. Teaspoonful every three hours. 



Colitis, with Pain. 

P* Tinct. opii camph., 10 minims. 
Bismuthi subnit., 2 grains. 
Aquae calcis, q. s. ad 4 drachms. 

M. Teaspoonful every two hours. 



Atonic Dyspepsia, with Constipa- 
tion. 

IJ Pulv. rad. ipecacuanha?, 1 grain. 
Pulv. rad. rhei, 10 grains. 
Sodii bicarbonat., 1 / 2 drachm. 
Tinct. nucis vomicae, 15 drops. 
Aquae, q. s. ad 2 ounces. 

M. Teaspoonful before each feeding 



To Abort Acute Tonsillitis. 
P* ( 'reosote, 8 drops. 

Tinct. myrrh, 2 ounces. 
Glycerine, 2 ounces. 
Aquae, 4 ounces. 
M. D. S.: Gargle every hour. 



Acute Tonsillitis. 

P* Tinct. aconit. rad. 

One drop every hour for six doses to a 
child 1 to 5 years old. 



Infantile Eczema. 

(Dry, vesicular and papular.) 
Leistikow recommends : — 
P* Zinci oxidi, 1 drachm. 
Amyli, 1 drachm. 
Adipis lanae, 1 drachm. 
Petrolati, 2y 2 drachms. 
Hydrar. oxid. flav., 4 to 8 grains. 
M. ft. pasta. 

Kistler employs the following oint- 
ment to relieve the itching of infantile 
eczema: — 
I£ Salicylic acid, 15 grains. 

Bismuth subnitrat., 4 drachms. 
Powdered starch, 1 1 / 2 drachms. 
Cold cream, 2 ounces. 
Calomel, in the dose of 1 or 2 grains, 
is indicated from one to three times a 
week, to aid in the elimination of patho- 
logic products. 



PRESCRIPTIONS. 



943 



Stimulating Expectorant Useful in 
Bronchitis. 

I£ Amnion, carbonat., l / 2 drachm. 
Tinct. senegse, 20 drops. 
Tinct. opii camphorat., 3 drachms. 
Syr. tolutan, 5 drachms. 
Aquae, q. s. ad 6 ounces. 

M. Teaspoonful every two or four 
hours. Diluted with water. 



Tuberculosis. 

I£ Creosote carbonate, 30 drops. 
Spiritus frumenti, 4 drachms. 
Glycerinae, 4 drachms. 
Aqua?, q. s. ad 4 ounces. 

M. Teaspoonful every four hours or 
oftener. 



Vaginitis. 
fy Alum, powdered, 1 ounce. 

Or: — 
1$, Zinc sulphate, 1. ounce. 

Or: — 
I£ Borax, 1 ounce. 

Sig. : A tablespoonful to a quart of 
water to be used as a vaginal injection 
three or four times a day. Apply a sterile 
pad of cheese-cloth. A fresh pad to be 
applied after each irrigation. 



Fever Mixture. 

Ifc Tr. aconite rad., 16 drops. 
Spir. mindererus, 2 ounces. 

M. Sig.: One-half teaspoonful every 
hour for a child 2 to 4 years old. 



Hypodermic Medication. 

When immediate relief is required, hypodermic medication should be 
given. The rapid action of hypodermic medication is best shown in giving 
a dose of apomorphia hypodermically for the relief of spasmodic croup. 



CHAPTEE XII. 

Eemedies Most Frequently Administered. 

For hypodermic use the dose should be half that used by the mouth. 
For use by rectum the dose should be twice that used by the mouth. 

Dose for Children. — Dr. Young's rule : Add 12 to the age, and divide 
the age by the result. 

Example. — For a child 2 years old, 1^L 2 = J # The dose should be 
1 / 7 that for an adult. 

In giving powerful medicines and opium still smaller doses must be 
used for children. 

TABLE OF DOSES. 
Owing to the toxic effect, drugs marked "*" must be given with greater caution. 



Remedies. 



*Acid, arsenious 

benzoic 

boric 

camphoric (to check night-sweats) . . . . 
*carbolic 

gallic 

gallic (in albuminuria) 

hydrobromic, diluted 

hydrochloric, diluted 

*hydrocyanic, diluted 

nitric, diluted 

nitrohydrochloric, diluted 

phosphoric, diluted 

salicylic 

sulphuric, aromatic 

sulphuric, diluted 

sulphurous 

tannic 

*Aconitina (white crystals) 

*Adonidin ( heart- tonic ) 

Aloes 

Aloinum 

Ammonii benzoas 

bromidum 

carbonas 

chloridum 

iodidum 

valerianas 

*Amyl nitris (inhaled or internally) 

Antimonii et potassii tartras (diaphoretic) 

et potassii tartras (emetic) 

oxysulphuret 

Antipyrin 

(944) 



Grains or Minims 

for Child 
Three Years Old. 



.003 to 0.01 

to 3 

to 2 

to 6 
.1 to 0.3 
.6 to 3 

to 12 

to 12 

to 4 
.4 to 1.2 

to 4 

to 4 

to 6 

to 4 

to 3 

to 6 

to 12 
.4 to 2 

.0007 to 0.001 
.02 to 0.065 
.4 to 1 
.025 to 0.6 

to 4 

to 6 
.6 to 2 

to 6 
.4 to 3 
.4 to 3 
.4 to 1 
.01 to 0.02 
.2 to 0.4 
.1 to 0.4 
.4 to 3 



TABLE OF DOSES. 



945 



Remedies. 



Apomorphine hydrochloride 

Argenti nitras . 

*Arsenii iodidum 

*bromidimi 

* Atropines sulphas 

*Auri et sodii chloridum 

Bismuthi subnitras 

salicylas 

*Bromoformum (in whooping-cough, etc.) 

Caffeine 

Calcii chloridum hydra turn 

Calcii lacto-phosphas 

Camphora 

monobromata 

Cerii oxalas 

Chinoidinum 

Chloral 

Chloralamidum (hypnotic) 

Chloroformum 

Chrysarobinum ( eczema ) 

Cinchonidina, and its salts 

Cocaina ( locally, 14 per cent, solution ) , internally .... 

Codeina 

^Colchicine -. 

ConfectiO sennee 

'Creolin (locally, % to 2 per cent, solution), internally 

Creosotum 

Croton-chloral 

Cupri acetas 

sulphas (emetic) 

'Digitalinum 

^Digitalis 

*Duboisina, and salts 

*Elaterinum (U. S. P., 1880) 

Emetina, and salts (emetic) 

Ergota 

Ergotinum 

'"Erythrophloeina (local anaesthetic, heart-tonic) 

h Eserina, and its salts 

Ethyl chloride (local anaesthetic) 

Fel bovis purincatum 

Ferri arsenas 

bromidum 

carbonas saccharatus 

et ammonii citras 

et ammonii tartras 

et potassi tartras 

et strychninae citras 

hypophosphis 

iodidum saccharatum 

lactas 

oxidum hydratum cum magnesia 

(antidote to arsenic) 

pyrophosphas 

subcarbonas 

60 



Grains or Minims 

for Child 
Three Years Old. 



0.0065 to 0.02 
0.035 to 0.1 
0.003 to 0.02 
0.003 to 0.012 
0.0015 to 0.006 
0.006 to 0.025 
1 to 12 
1 to 4 
1 to 2 
0.2 to 1 
1 to 4 
1 to 2 
0.6 to 2 
0.4 to 1 
0.2 to 2 
0.6 to 6 
0.6 to 4 
3 to 12 
0.2 to 6 
0.035 to 0.6 
1 to 6 
0.012 to 0.1 
0.012 to 0.4 
0.002 to 0.004 
12 to 24 
0.1 to 1 
0.1 gradually- 
increased 
0.2 to 1 
0.025 to 0.1 
0.012 to 0.05 
0.003 to 0.006 
0.025 to 0.4 
0.0015 to 0.0033 
0.0035 to 0.016 
0.025 to 0.05 
3 to 12 
0.4 to 1.6 
0.012 to 0.025 
0.003 to 0.01 

1 to 2 

0.01 to 0.035 
0.2 to 1 
0.4 to 3 
1 to 2 

1 to 3 

2 to 6 
0.2 to 1 
1 to 2 
0.4 to 1 
0.2 to 0.6 

f3 0.8 to f3 1.6 

frequently 
0.2 to 1 
1 to 6 



946 



MISCELLANEOUS. 



Remedies. 



Ferri sulphas 

sulphas exsiccatus 

valerianas 

Ferrum dialys 

reductum 

Gaultheria, oil of 

Guaiacol (constituent of creosote) 

Guaiacol carbonas vel benzoas 

Homatropinse hydrobromidum (mydriatic, locally, 0.2 per 

cent, to 4 per cent. ) 

*Hydrargyri chloridum corrosivum 

*chloridum mite 

*Hydrargyri iodidum rubrum 

iodidum vir 

subsulphas flava (as emetic) 

Hydrargyrum cum creta 

Hydrastine 

Hydrogenii dioxidum (10-volume solution), locally, {25 to 

100 per cent. ) , antiseptic 

*Hyoscinae hydrobromas 

*Hyoscyaminae sulphas 

Ichthyol (locally, 10 to 50 per cent.), internally 

Infusum digitalis 

Iodoformum 

Iodol 



Commencing doses 
to be 

increased cautiously 



Iodum 

Ipecacuanha (expectorant) 

" ( emetic ) 

Jalapa 

Liq. ammonii acetatis 

acidi arseniosi "1 

arsenii bromidi | 

arseni et hydrargyri iodidi 

potassii arsenitis 

sodii arseniatis J 

ferri chloridi 

ferri dialys 

potassii citratis 

Lithii benzoas 

bromidum 

carbonas 

citras 

salicylas 

Lupulinum 

Magnesii carbonas 

citras, gran 

sulphas 

Mangani oxidum niger 

Methylene blue with powdered nutmeg (malarial fevers) 
Mistura chloroformi 

ferri et ammonii acetatis 

glycyrrhizae composita 

potassi citras 

rhei et sodse 

Morphina, and its salts 

Morrhuol (derivative of cod liver-oil) 

Moschus 

Naphthol 

*Nitroglycerinum (trinitrin), % per cent, solution 



Graixs orMim.ms. 

for Child 
Three Years Old 



0.2 to 


0.6 


0.1 to 


0. 


5 


0.2 to 


0.6 


0.2 to 


3 




0.2 to 


1 




0.6 to 


•1 




0.05 to 1 


0.065 


to 


2 


0.035 


to 


0.5 


0.003 


to 


0.02 


0.012 


to 


2 


0.004 


to 


0.02 


0.035 


to 


0.2 


0.4 to 


1 




0.6 to 


1.6 


0.6 to 


1 




6 to 24 




0.001 


to 


0.0035 


0.001 


t.» 


0.003 


0.6 to 


1 




f 3 0.2 


to 


f3 0.8 


0.2 to 


1 




0.035 


to 


0.1 


0.02 to 0.05 


0.035 


to 


0.2 


3 to 6 




3 to 6 




£50.4 


to 


f3 1.6 



0.2 to 1 



0.4 to 2 

2 to 6 

f3 0.4 to f3 0.8 

1 to 4 

1 to 4 

0.4 to 2 

1 to 4 

1 to 6 

1 to 6 

3 to 12 

3 0.4 to 3 1.6 

2 to 6 
0.2 to 1 
0.2 to 1 

f3 0.2 to f3 1.6 
f3 0.2 to f3 0.8 
f3 0.2 to f3 0.8 
f3 0.8 to f3 3.2 
f3 0.8 to f3 1.6 
0.0012 to 0.006 
0.6 to 12 
0.4 to 3 
0.4 to 1 
fftt. 0.5 increased 



TABLE OF DOSES. 



947 



Remedies. 



Oleoresina aspidii ( filix mas ) 

Opium ( 14 per cent, morphine) 

Phenocoll hydrochloride 

•Phosphorus 

*Physostigminae sulphas 

*Picrotoxinum 

*Pilocarpina, and salts (cautiously) 

Piperazin 

Plumbi acetas 

Potassii acetas 

bicarbonas 

Potassi bromidum 

bitartras 

chloras 

cyanidum 

iodidum 

nitras 

permanganas 

tartras 

Pulvis antimonialis 

glycyrrhizse compositus 

ipecacuanha? et opii 

jalapae compositus 

rhei compositus 

Resina copaibae 

euonymi 

guaiaci 

jalapse 

podophylli 

scammonii 

Resorcin 

Rheum 

Saccharine ( substitute for sugar ) 

Salicinum 

Salipvrin (antipyretic, antineuralgic) 

Salol 

Salophen (antipyretic, antirheumatic).... 

Santonium 

Senna 

*Sodii arsenas 

benzoas 

boras (in epilepsy) 

bromidum 

chloras 

hyposulphis 

iodidum 

phosphas 

salicylas 

*Sparteinae sulphas (cardiant and diuretic) 
Spiritus setheris nitrosi 

setheris compositus 

ammoniae aromaticus 

camphorae 

chloroformi 

Strontii lactas vel bromidum vel iodidum. 

*Strychnina, and salts 

Sulphonal (best in hot mint- water) 



Grains or Minims 

for Child 
Three Years Old. 



to 3 

025 to 0.4 

6 to 3 

0015 to 0.004 

0015 to 0.004 

0016 to 0.004 

003 to 0.001 
(daily) 

1 to 0.6 
to 12 

6 to 12 
6 to 12 

2 to 0.4 
6 to 6 

01 to 0.025 

4 to 6 
4 to 3 

1 to 1 

0.2 to 3 1.6 

2 to 0.6 
to 12 
to 3 

to 12 

to 12 
4 to 2 
4 to 1 
to 4 
4 to 1 
016 to 0.1 
4 to 2 
4 to 1 
4 to 6 
1 to 1 

to 6 
6 to 3 

4 to 2 
to 4 

05 to 1 

6 to 36 

003 to 0.02 
to 3 

to 6 
to 6 

4 to 1 
to 4 

4 to 6 
4 to 24 

to 6 

012 to 0.8 

to 24 

to 24 

to 12 

to 6 

to 12 

to 12 

003 to 0.016 

to 4 



948 



MISCELLANEOUS. 



Remedies. 



Sulphur 

Syr. ferri bromidi 

ferri iodidi 

scillae eompositus 

senegie 

senna? 

Terebene 

Terpin hydrate (tonic expectorant) 

Theobromine et sodii salicylas (diuretic I 

Thymol 

*Tinctura aeoniti 

aloes 

asaf<etidue 

belladonna? 

cannabis indicae 

capsici 

ciniicifugae 

cinchonae composita 

colchici seminis 

conii 

*digitalis . 

ferri chloridi 

gelsemii 

guaiaci ammoniata 

hydrastis 

hyoscyami 

*ignatiae 

iodi compositus 

kino 

lobelias 

moschi 

nucis vomicae 

*opii 

opii camphorata 

*physostigmatis 

stramonii 

strophanti^ (cardiant and diuretic) 

Valerianae ammoniata 

veratri viridis ' 

*Trional ( hypnotic ) 

Trituratio elaterini (10 per cent, i 

Vinum antimonii (expectorant and alterative) 
(emetic) 

colchici 

ergotae 

ipecacuanhas (expectorant ) 

( emetic ) 

opii 

Zinci acetas 

bromidum 

iodidum 

oxidum 

phosphidum 

sulphas (emetic) 

valerianas 



Grains ok Mpmis 

fob Child 
Tiikee Years Old. 



3 0.1 to 3 0.8 

1 to 12 

1 to 6 

1 to 6 

13 0.2 to f3 0.4 

f3 0.2 to f5 1.0 

1 to 3 

0.4 to 1 

1 to 6 

0.2 to 1 

0.1 to 1 • 

3 to 12 

G to 12 

0.4 to 3 

1 to 4 

1.6 to 3 

to 12 
3 to 24 

1 to 4 

1 to 6 
0.6 to 3 

2 to 6 
0.4 to 3 
6 to 12 
6 to 24 
1 to 6 

1 to 
1.4 to 3 

3 to 24 
1 to 6 
3 to 12 
1 to 3 
0.4 to 3 
1 to 48 
1 to 3 

1 to 3 
0.2 to 2 

2 to 24 
0.6 to 2 

3 to 12 
'M>^:. to 0.2 
o.2 to 1.6 

6 to 1.5 

1 to 3 

f3 0.2 to f3 0.6 

1 to 3 

f3 0.4 to f3 1.2 

1 to 3 

0.1 to 0.4 

0.1 to 1 

0.1 to 0.6 

0.2 to 1 

0.02 to 0.035 

3 to 6 

0.1 to 1 



INDEX. 



Abdomen, 261; in ascites, 392; tapping, 394; 
in cretinism, 760; in Henoch's purpura, 
750; in intussusception, 319; in peri- 
tonitis, 388; in pseudo-leukaemic anaemia, 
737; in rachitis, 342; in typhoid, 694; in 
dislocation of the hips, 900. 
Abdominal band, 20. 

in gastroptosis, 258; in pertussis, 496. 
Abnormal growths. 884. 
Abnormalities, congenital, 53. 

of air passages, 56. 
Abortive pneumonia, 499. 
Abscess, alveolar, 233. 
cerebral, 843; in measles, 639. 
complicating Pott's disease, 893; vaccina- 
tion, 686. 
due to hernia, 894; sacral or iliac disease, 

894. 
hepatic, caused by worms, 325. 
in angina Ludovici, 233. 
in perinephritis, 409, 410; pyelitis, 412. 
ischio-rectal, 329. 

of brain, 843; diagnosis, 844; etiology, 843; 
pathology, 843; prognosis, 845; symp- 
toms, 844; treatment, 845; surgical, 845; 
. of cervical region, 894; of inguinal re- 
gion, 894; of loin, 894; of spine, 894; of 
thoracic region, 894. 
peritonsillar, 433; resembling diphtheria, 558. 
retro-oesophageal, 234. 
retro-pharyngeal, 442; complicating scarlet 

fever, 655. 
subphrenic, 385. 
Abscesses, in erysipelas, 703; in typhoid, 698. 
multiple, complicating cerebro-spinal men- 
ingitis, 824; scarlet fever, 660. 
renal, in urinary passages, 412. 
of thymus, 773. 
Acetonuria, 415; in diabetes mellitus, 419. 
Acid, carbolic, as disinfectant, 935. 
hydrochloric, in gastric contents, 237, 915. 
lactic, in gastric contents, 237, 915. 
Actinomycosis, 233. 

Acute fatty degeneration of the new-born, 50. 
meningitis, 824. 
milk infection, 299. 
Addison's disease, 774. 

Additional foods during nursing period, 76. 
Adenitis, acute, 754; pathology, 754; prog- 
nosis, 754; symptoms, 754; treatment, 
754; abortive, 754; surgical, 754. 
chronic, 755; d'agnosis, 755; pathology, 755; 

symptoms, 755; treatment, 755. 
retropharyngeal lymph, 443. 
tubercular, 755; diagnosis, 756; from Hodg- 
kin's disease, 757; from syphilis, 756: 
pathology, 755: symptoms. 755; treat- ! 
ment, 757: surgical, 757. 



Adenoid vegetations, 438; diagnosis, 439; 
pathology, 438; prognosis, 440; symp- 
toms, 438; bedwetting, 4:*9; deafness, 
439; treatment, 441; anaesthetic, 441; 
operation, 441; haemorrhage after, 442. 
a point of entrance of tubercle bacilli, 518. 
causing deafness, 435; enuresis, 423. 
congenital, 55. 
face, 439. 

method of examining for, 439, 440. 
Adherent prepuce, 397; treatment, 397. 
Adhesia linguae, 55. 

Adhesions, in pleurisy, 463; in chronic em- 
pyema, 470. 
Administration of drugs, 936. 
Adrenal glands, diseases of, 774. 
Adulteration of milk, 912 (see also Milk Pre- 
servatives, 112). 
Ague (see Malarial Fever), 706. 
Air passages, abnormalities of, 56. 
Airing, out of doors, 20. 
Alalia idiopathica, 845. 

Albumin, concentrated preparations of, 205. 
in milk, effect of heat on, 165. 
in urine, 918; test for, 921. 
transformation of, by gastric juice, 238. 
water, 905. 
Albuminoids in cows' milk, 121. 
Albuminuria, 918; in malarial fever, 714; in 
measles, 633; in nephritis, 406, 919. 
lordotic, 416. 
orthostatic, 416. 

transient, in scarlet fever, 656. 
Albumoscope, 922. 
Alcohol, content in liquid foods, 208. 

internally, 214; abuse of, 274. 
Almond milk, 905. 

Alveolar abscess, 233; symptoms, 233; treat- 
ment, 233. 
arch, in adenoid vegetations, 438. 
Amaurotic family idiocy, 849. 
Amoebic dysentery, 278. 

Amyloid degeneration, in diphtheria, 919; in 
malaria, 919; in rachitis, 919: in scarla- 
tina, 919; in syphilis, 919; in tubercu- 
losis, 919. 
of the liver, 383. 
Amylopsin ferment test, 250. 
Anaemia, 733; associated with masturbation, 
796. 
acquired, 733. 
congenital, 733. 
following diphtheria, 561; pertussis, 488; 

scarlet fever, 661. 
in Addison's disease, 774. 
infantum pseudo-leukaemica, 736. 
pernicious, 734. 
pretubercular, 530. 



(949) 



950 



INDEX. 



Anaemia (concluded), 
pseudo-leuksemic, 736. 
secondary, 734. 
splenic, 733. 
Anaemic murmurs, 367. 
Anaesthesia, 930. 
intra-spinal, 932. 

local, by injection of sterile water, 932 
partial, in multiple neuritis, 794. 
Anaesthetic, chloroform, 930; ether, 931; ethyl- 
chloride, 931; nitrous oxide, 930. 
in adenoid operation, 441; in empyema, 469; 
in tonsillotomy, 436. 
Analyses of cows' milk, 99, 100; woman's 

milk, 67, 120. 
Anasarca, general, in leukaemia, 736; in 
nephritis complicating scarlet fever, 666; 
in post-scarlatinal nephritis, 659; in 
tuberculosis of the lung, 538. 
Angeioma, 53, 888. 
Angina Ludovici, 233. 
pseudo-membranosa in scarlet fever, 652; 

scarlatina membranosa, 653. 
tonsillaris, 430. 
Ani, prolapsus, 330. 
Ankle, oedema of, in chlorosis, 738. 
Ankle-joint and tarsus, diseases of, 902. 

in rachitis, 342. 
Anorexia, in acute tuberculosis, 530; in 
measles, 630; in meningitis, 827; in rheu- 
matism, 741; in rubella, 623. 
Antibacterial action of the blood, 730. 
Anticolic nipple, 158. 
Antimeningitis serum, 831. 

Antipyretics, in broncho-pneumonia, 460; in 

cerebral pneumonia, 511; in influenza, 

485; in scarlet fever, 672; in typhoid, 693. 

Antistreptococcus serum, in erysipelas, 703, 

705; in scarlet fever, 668. 
Antitoxin, diphtheria, 570; in treatment of 
meningitis, 832. 
eliminated by woman's milk, 69. 
in tetanus, 801; in typhoid, 699. 
rashes, 555. 

streptococcus, in treatment of erysipelas, 
703, 705; of scarlet fever, 668. 
Anus, absence of, 59. 
atresia of, 59. 

condylomata of, in syphilis, 720, 721. 
congenital narrowing of, 59. 
fissure of, 328. 
Aorta, 367; area of murmur, 367. 
Aortic bruit, 368; from aneurism, 368. 
systolic murmur, 368. 

valves, in diastolic murmurs, 367; cusps in, 
368. 
Aphasia, complicating cerebral paralysis, 836; 
diphtheria, 559; pertussis, 489; typhoid, 
698. 
following pertussis, 489. 
Aphonia, due to paralysis, 4. 
in hereditary ataxy, 809. 
spastica, intubation in, 593. 
Aphthae, Bednar's, 225. 
Apoplexy, in pertussis, 489. 



Appendicitis, 312; bacteriology, 312; causes, 
313; course and prognosis, 315; differen- 
tial diagnosis, 314; from abscess of 
ovary, 315; from colic, 315; from intus- 
susception, 315; from hip-joint disease, 
315; symptoms and diagnosis, 313; treat- 
ment, 316; when to operate, 316. 
catarrhal, 313. 

false (see pseudo-appendicitis), 316. 
gangrenous, 313. 
mild forms, 313. 
ulcerative, 313. 
Appendicular lithiasis, 313. 
Appendix, vermiform, location of, 262. 
Appetite, abnormal, 255. 
in gastroptosis, 256. 
loss of, 333; due to catarrh, 429. 
Arm in birth palsy, 41. 
Arnold steam sterilizer, 164. 
Arthritis, 903; bacteriology, 903; diagnosis 
and differential diagnosis, 904; from 
rheumatism, 904; from scarlet fever, 
904; etiology, 903; prognosis, 904; 
symptoms, 904; treatment, 904. 
following empyema, 903; measles, 903; scar- 
let fever, 903; traumatism, 903. 
Arthrogryposis (see Tetany), 798. 
Articular rheumatism, 742. 
Artificial feeding (see Bottle or Hand Feed- 
ing), 139. 
Ascaris lumbricoides, 325. 

Ascites, 392; causes, 393; diagnosis, 393; 
etiology, 393; pathology, 393; symptoms, 
393; treatment, 393; tapping the ab- 
domen, 394. 
due to peritonitis, 393. 
Asphyxia during intubation, 591. 
in diphtheria, 561; in retro-pharyngeal ab- 
scess, 443. 
neonatorum, 42; causes, 42; treatment, 43. 
Aspiration (see Lumbar Puncture), 
in ascites, 394; in encephalocele, 817; in 
hydrocephalus, 816; in nephritis, com- 
plicating scarlet fever, 666. 
of chest in pleurisy with effusion, 465; of 
pericardium, 377. 
Asthma, bronchial, 455. 
dyspeptic, 260. 
thymic, 773. 
Ataxia, hereditary, 808. 

Atelectasis pulmonum, complicating per- 
tussis, 489. 
in bronchitis, 453; in diphtheria, 580; in 

premature infants, 31. 
differentiated from pneumonia, 509. 
Athetosis in cerebral paralysis, 836. 
Athrepsia infantum, 356; etiology, 356; pathol- 
ogy, 357; prognosis and course, 358; 
symptoms, 357; treatment, 359. 
fatty livers in, 357. 
feeding in, 359; buttermilk, 187. 
tetany in, 798. 
Atomizer, 426; oil, 445; steam, 446. 
Atony, general, in gastroptosis, 256. 
of intestine, 333. 



INDEX. 



951 



Atresia ani, 59. 

Atrophy, infantile (see Athrepsia), 356; urine 
in, 918. 
in acute myelitis, 806; in multiple neuritis, 

794. 
in pseudohypertrophic paralysis, 842. 

Aura of epilepsy, 803; of hysteria, 791. 

Auscultation, in asthma, 450; in bronchitis, 
453; acute catarrhal, 450; capillary, 450; 
in emphysema, 450; in fluid or air in 
pleural sac, 450; in pleurisy, 450; sub- 
acute, 450; in pneumonia, 450; in tuber- 
culosis, 451. 
of anterior fontanel, 775. 

Auto-intoxication, 319. 

Babcock's milk test, 117. 
Babinski reflex, 779, 826. 
in hereditary ataxia, 809; in tubercular 
meningitis, 822. 
Bacillary diphtheria of the colon, 278. 
Bacillus of diphtheria, 539; of Eberth, in ty- 
phoid, 689, 690; of influenza, 479; in 
bronchitis, 452; of Pfeiffer, 479. 
Klebs-Loeffler, 539, 541; stain for, 929. 
pyocyaneus, in bronchitis, 452. 
Shiga, in dysentery, 280. 
tubercle, 519; stain for, in sputum, 988. 
typhoid, 690. 

Vincent's, in ulcero-membranous tonsillitis, 
432. 
Backache in lateral curvature of the spine, 

897. 
Backhaus's milk, 190. 
Back-knee in rachitis, 355. 
Backwardness, 3; differentiated from idiocy, 
846. 
in speaking, 845. 
Bacteria, action of saliva on, 237. 
in bronchitis, 452; in broncho-pneumonia, 
457; in cows' milk, 63, 113; in cystitis, 
421; in empyema, 467; in erysipelas, 702; 
in follicular tonsillitis, 432; in measles, 
628; in perinephritis, 409; in pertussis, 
487; in vaginitis, 400; in woman's milk, 
62. 
influence of gastric juice on, 237. 
of the intestines, 268. 
Bacteriological memoranda, 928. 
stain for diplococcus pneumonias, 929; gono- 
coccus, 929; Klebs-Loeffler bacillus, 929; 
meningococcus, 929; streptococcus, 929. 
Bacterium coli commune, 268; biological char- 
acters, 269; morphology, 269; patho- 
genesis, 271. 
in broncno-pneumonia, 457; in cystitis, 421. 
Bacterium lactis aerogenes, 271; biological 
characters, 272; morphology, 271; patho- 
genesis, 273. 
Baginsky tonsillotome, 436. 
Baldness of occiput, in rachitis, 346; in 

scurvy, 339. 
Band, abdominal, 20; in gastroptosis, 258; in 

pertussis, 4»6. 
Barley jelly-, 148; water, 147. 



Barlow's disease, 335. 

Basedow's disease (see Exophthalmic Goiter), 

772. 
Basham's mixture, 667. 
Basilar meningitis (see Meningitis), 819. 
Bath, at birth, 17; temperature of, 18. 
bichloride, in syphilis, 725. 
cold, sponge, 23; spray, in hysteria, 793; 
tub, in typhoid, 699, 732; hot air, 666; 
hot and cold, in asphyxia neonatorum, 
44. 
hot, as a diaphoretic, 665. 
in diphtheria, 570; in hysteria, 793; in rheu- 
matism, 745; in syphilis, 725; in typhoid, 
699, 732. 
oatmeal, 18. 

sulphur, in rheumatism, 745. 
thermometer, 18. 
Bednar's aphthae, 225. 

Bed- wetting, a symptom of phimosis, 397; 
caused by presence of adenoids, 423, 439. 
Beef-juice, 905. 
Bell's paralysis, 842. 
Bicarbonate of soda solution, 130. 
Biedert's cream, 134; how to make, 135. 
Bifid tongue, 832. 

uvula, 232. 
Bile, 381. 

Bile-ducts, congenital obliteration of, 35; eti- 
ology, 35; pathology, 35: symptoms, 36. 
Bilious attack (see Acute Intestinal Indiges- 
tion), 296. 
Birth palsy, 40. 

Bladder, 413; extroversion of, 413, 
location of. 413. 
proper training of, 22. 
stone in, 420. 
washing, 420, 421. 
Bleeders (see Haemophilia), 751. 
Blepharitis, 866. 

Blindness following meningitis, 831. 
Blisters (see Burns), 881. 
Blood, 726; antibacterial action of, 730. 
at birth, 726; corpuscles, red, 726; white, 
727; size of, 727; haemoglobin, 727; spe- 
cific gravity, 727. 
circulation of, during foetal period, 361; in 

early life, 362. 
crisis, in pneumonia, 508. 
erythroblasts, 728. 
examination of, 711; to prepare specimen, 

695; in a case of meningitis, 827. 
in anaemia, 733; in bronchitis, 728; in chloro- 
sis, 738; in diphtheria, 548, 559, 728; in 
erysipelas, 728; in fever, 731; in gastro- 
intestinal diseases, 728; in hereditary 
syphilis, 728; in infectious diseases, 728; 
in malarial fever, 706; in multiple neu- 
ritis, 794; in nephritis, 406; in nervous 
diseases, 728; in perinephritis, 410; in 
pneumonia, 508, 728; in rachitis, 728; in 
scarlet fever, 645, 728; in skin diseases, 
728; in typhoid, 695; in Winckel's dis- 
ease, 50. 
letting, local (see Venesection), 938. 



952 



IXDEX. 



Blood (concluded), 
pathological conditions in disease, 728. 
reaction of pus, 730. 
smear, method of taking, 730. 
Blood-vessels (see also Thrombosis), dilata- 
tion of, in angeioma, 53. 
in haemophilia, 751; in spinal paralysis, 809; 
in syphilis, 718. 
Bloody urine (see Hematuria), 417; in diph- 
theria, 552; in septic diphtheria, 554, 559. 
Blue baby, 369. 

Boil (see also Furuncle), 877. 
Bone-marrow, in leukaemia, 735. 
Bones (see Fractures; also Joints), 
in hydrocephalus, 815; in rachitis, 348; in 
syphilis, 721; in tuberculosis, 721. 
Borborygmus, 296. 
Bothriocephalus latus, 323. 
Bottle-brush, 158. 
Bottle-feeding, 139. 
formulae, 140. 
rules for, 139. 
utensils required for, 139. 
Bottles, feeding, 157. 
Bovine tuberculosis, 518, 530. 
Bowel movements (see Stools). 
Bowels, inflation of, in intussusception, 322. 
obstruction of (see Intussusception), 318. 
proper training of, 22. 
Bow-legs, 3; in rachitis, 348, 355. 
Bradycardia, 366; in diphtheria, 552. 
Brain, 778; cerebellum, 779; convolutions of, 
779; difference between infantile and 
adult, 779; fissure of Rolando, 779; Syl- 
vius, 778; growth and development of, 
778; pia mater, 778; subarachnoid space, 
778. 
abscess of, 843. 
concussion of, 850. 

engorgement of, in cerebral pneumonia, 512. 
in tubercular meningitis, 820. 
water on, 814. 
Breast-feeding, 71 ; dangers of suffocation 
during, 72; disturbances during, 73; dur- 
ing pregnancy, 90; schedule for, 71; 
suggestions for, 72. 
Breast milk (see Milk, Woman's). 
Breast-pump, 67, 94. 

Breasts, massage of, during lactation, 95; 
pear-shaped, best adapted for nursing, 
89. 
Breath, in alveolar abscess, 233; in lithaemia, 
751; in pulmonary gangrene, 462. 
offensive, in stomatitis gangrenosa, 228. 
Breathing (see also Respirations), 451. 
Cheyne-Stokes, in meningitis, 823; in tuber- 
cular pneumonia, 515. 
in bronchial asthma, 455; in diphtheria, 553; 
in dry pleurisy, 464; in empyema, 467; 
in pleurisy, with effusion, 465; in tuber- 
culous pneumonia, 515. 
labored, in retro-pharyngeal abscess, 443. 
Breck's feeder for premature babies, 29. 
Bright's disease (see Nephritis), 405; urine 
in, 919. 



Bromide, administration of, per rectum, 939. 

of ethyl, as an anaesthetic, 931. 
Bronchi, diseases of, 450. 
in bronchitis, 452; in tuberculous pneu- 
monia, 515. 
Bronchial asthma, 455; etiology, 455; pathol- 
ogy, 455; symptoms, 455; treatment, 
456. 
catarrh, 452. 

glands, enlarged, causing bronchial asthma, 
455. 
Bronchitis, 452; bacteriology, 452; blood in, 
728; diagnosis, 453; diet in, 454; emetics, 
654; inhalations, steam, 454; pathology, 
452; prognosis, 453; pulse-rate, 453; res- 
pirations, 453; sputum, 453; symptoms, 
453; treatment, 454. 
an early symptom of typhoid, 694. 
complicating typhoid, 694. 
Broncho-pneumonia, 456; bacteriology, 457; 
differential diagnosis from atelectasis, 
460; fibrous pneumonia, 460; etiology, 
456; pathological anatomy, 457; physical 
examination, 459; predisposing causes, 
457; prognosis and course, 460; symp- 
toms, 458; treatment, 460; antipyretics, 
460; emetics, 461; expectorants, 462; 
pneumonia jacket, 461. 
complicating diphtheria, 559; measles, 636; 

pertussis, 488; variola, 685. 
sequela, tetany, 798. 
tuberculous, 535. 
Broths, 907. 

Brudzinski's neck sign in meningitis, 826. 
Buhl's disease, 50. 
Bulgarian milk, 183. 

Bulimia, 255; a symptom of hysteria, 255. 
Burns, 881. 

Buttermilk feeding, 182; how to prepare, 183. 
Byrd method of resuscitation, 43. 

Caecum, 262. 

Caffeine, effect of, 213. 

"Caking" of breast, 95. 

Calcined magnesia, 141. 

Calculi, giving rise to bloody urine, 417. 

in bladder, 420; diagnosis, 420; symptoms, 
420; treatment, 420. 

urethral, 420. 

vesical, 420. 
Caloric method of feeding, 166. 
Cancrum oris (see Stomatitis Gangrenosa), 227. 
Cane sugar, 119. 
Cantharidal collodion, 938. 
Capillaries in haemophilia, 752; in malarial 

fever, 710. 
Caput succedaneum, 58. 
Carbolic acid as a disinfectant, 935. 
Carcinoma, 887. 
Cardiac diseases, classification of, 366. 

paralysis, 563; symptoms, 563; in dysentery, 
282. 
Carious teeth, in rachitis, 346. 

possible point of entrance of tubercle 
bacilli, 518. 



INDEX. 



953 



Casein, 124; in cows' milk, 63; in woman's 
milk, 62, 66. 
milk, 124. 
Caseinogen, 122. 

Casts in urine, in nephritis, 407. 
Catarrh, acute nasal, 425; diagnosis, 425; eti- 
ology, 425; symptoms, 425; treatment, 426. 
bronchial, 452. 
follicular, 431. 
gastric, 42S. 
in syphilis, 719. 
naso-pharyngeal, 428. 
with adenoid growths, 425. 
Catarrhal conjunctivitis, 861. 
croup, 444. 
epidemic, fever, 479. 
jaundice, 252. 
nephritis, 656. 
pneumonia, 456. 
proctitis, 328. 
Cavities of the lung, in pulmonary tuber- 
culosis, 536; in tuberculous pneumonia, 
514. 
Cellulitis, complicating vaccination, 686. 

of neck, in scarlet fever, 655. 
Centrifugal milk-testing machine, 117. 
Cephalhsematoma, 57; spurious, 58. 
Cereal milk, 197; analysis of, 198. 
Cerebellum, 779; abscess of, 843. 
Cerebral abscess, 843. 
congestion, in pneumonia, 512. 
haemorrhage, in pertussis, 489. 
hernia, 817. 

hyperaemia, in insolation, 851. 
paralysis, 834. 
pneumonia, 502. 
Cerebro-spinal meningitis, 824. 
Cerebrum, 779. 

Certified milk in New York City, 103. 
Cestodes, 323. 

Chamomile injections, 294. 
Chatillon weight scale, 216. 
Chemical examination of cows' milk, 116; 
gastric contents, 915; urine, 917; wom- 
an's ( milk, 65. 
Chest, in broncho-pneumonia, 636; in cerebral 
pneumonia, 507; in chronic pericarditis, 
377; in empyema, 476; in pleurisy with 
effusion, 465; in rachitis, 347; in spas- 
modic laryngitis, 445. 
strapping of, in dry pleurisy, 464; in 
pleurisy with effusion, 466. 
Cheyne-Stokes respiration, in tubercular 
meningitis, 826; in tuberculous pneu- 
monia, 515. 
Chicken-pox (see Varicella), 676. 
Childhood, 1. 

Chills, in diphtheria, 551; in orchitis compli- 
cating mumps, 758; in perinephritis, 410. 
Chloasma, 873. 

Chloral hydrate, in convulsions, 783. 
Chloride of lime, as a disinfectant, 935. 
Chloroform, 930; in control of spasms, 783. 
Chlorosis, 737; diagnosis, 738; etiology, 7:57 : 
pathology, 737; prognosis, 738; symp- 



toms, 738; blood in, 738; treatment, 738; 
exercise, 738; nutrition, 739. 
Chocolate, 212; how to prepare, 905. 
Cholera infantum, 302; resembling typhoid, 

696. 
Choleriform diarrhoea, 299. 

Chorea, 786; course, 789; etiology, 786; ade- 
noids, 787; overstudy in school, 787; 
polypoids, 787; sedentary life, 787; pathol- 
ogy, 788; prognosis, 789; symptoms, 
788; heart, 789; treatment, 789; rest, 789. 
Chvostek's phenomena, 799. 
Circulation, changes in, at birth, 361. 

foetal, 361. 
Circumcision, tuberculosis infection through, 
519. 
in treatment of masturbation, 797. 
operation for, 398. 
Cirrhosis of the liver, 384. 
Cleft palate, 54; feeding in, 54. 
Clothing, 19; abdominal band, 20; for feet, 
19; in summer, 19; in winter, 19; night, 
20. 
Clinical thermometers, disinfection of, 934. 
Clitoridectomy, in masturbation, 797. 
Cocaine as an intra-spinal anaesthetic, 932. 
Cocoa, 211; how to prepare, 905. 
Coffee, 213; contraindications, 213; indications, 

213. 
Cold, as an antiypretic, 461; in typhoid, 699. 
compresses, 461. 
ice collar, in tonsillitis, 430; bag, in typhoid, 

701. 
pack, 485; in chorea, 790; in pneumonia, 510*. 
sponge bath, 23. 
spray bath, in hysteria, 793. 
Colic, a symptom of worms, 325. 
caused by excess of sugar, 121; by proteid 

indigestion, 96. 
in breast-fed babies, 294. 
intestinal, 293. 
Colicystitis, 419; bacteriology, 419; pathology, 

419; symptoms, 419; treatment, 420. 
Colitis (see Ileo-colitis), 278. 
amoebic, 278. 
diphtheritic, 278, 279. 
mucous, in syphilis, 719. 
Collapse, in diphtheria, 553; in dysentery, 282. 

pulmonary (see Atelectasis Pulmonum). 
Colles's law, 717. 

Collodion, cantharidal, 938; iodoform, in tu- 
bercular meningitis, 823; salicylic, in 
mumps, 757. 
Colon bacillus, in bronchitis, 452; in peri- 
nephritis, 409. 
course of, 261. 

flushing, in athrepsia infantum, 360; in in- 
testinal colic, 295. 
irrigation of, in diarrhoea, 274; in dysentery, 
283; in typhoid, 699. 
Colored race, mortality in, from tuberculosis, 

525. 
Colostrum, 61; analysis of, 64; corpuscles of, 
61; proteids in, 87. 



954 



IXDEX. 



Coma, in angina Ludovici, 233; in cerebral 
pneumonia, 501; in influenza, 482; in 
pachymeningitis, 832; in scarlet fever, 
665; in tubercular meningitis, 823. 
to relieve, 512. 
Combustio (see Burns), 881. 
Composition of cows' milk, 99; woman's milk 
compared with different infant foods, 
204. 
Concussion of the brain, 850. , 
Condensed milk, 191; analysis of, 192; quan- 
tity of sugar in, 191. 
causing scurvy, 335. 
Condylomata, in syphilis, 720. 
Congenital (see also Foetal) abnormalities, 53. 
adenoids, 55. 
cysts of the kidney, 58. 
dislocation of hip, 899. 
heart lesions, 369. 
idiocy, 846. 

malformations, 53; of the rectum, 59. 
obliteration of the bile-ducts, 35. 
sacral tumor, 58. 
stenosis of the larynx, 56, 720. 
syphilis, 723, 724. 
Congestion of the liver, 382. 
Conjunctiva, infection of, 862. 

inflammation of, in acute nasal catarrh, 426. 
Conjunctivitis, acute catarrhal, 861; cleansing 
the eye in, 861. 
diphtheritic, 863. 
membranous, 863. 
phlyctenular, 868. 
Constipation, 283; causes, 284; anatomical, 
284; mechanical obstruction, 285; sys- 
temic, 285; proteid indigestion, 96; steril- 
ized milk feeding, 162; symptoms, 287: 
treatment, 287; cold water injections, 
289; diet, 291; electricity, 290; enema, 
288; massage, 290; suppositories, 289. 
alternating with diarrhoea, 253. 
in chlorosis, 738; in cretinism, 760; in diph- 
theria, 553. 
to correct, in bottle-fed infants, 114; in 
breast-fed infants, 97, 287. 
Convulsions, 781; diagnosis, 782; etiology, 781; 
pathology, 782; symptoms, 782T treat- 
ment, 783. 
a symptom of worms, 325. 
during teething period, 6, 783. 
epileptic, 802. 

in auto-intoxication, 319; in cerebral pneu- 
monia, 501; in diphtheria, 553, 559; in 
dysentery, 282; in hydrocephalus, 815 
in influenza, 480; in lithaemia, 751; ii 
meningitis, 826; in pachymeningitis, 833 
in pertussis, 489; in post-scarlatinal 
nephritis, 659; in scarlet fever, 647, 650 
in typhoid, 693. 
lumbar puncture, 783. 
Coprostasis, 333. 
Cord, umbilical, management of, 16; separa 

tion of, 1. 
Corpuscles of blood, 726. 



Coryza, 425. 
in measles, 630; in rubella, 623; in syphilis, 
723. 
Cough, croupy, 444, 557. 
hacking, in variola, 685. 

in acute tuberculosis, 530; in croup, 444; in 
dry pleurisy, 463; in pertussis, 487, 488; 
in pleurisy with effusion, 465; in tuber- 
culous pneumonia, 515; in variola, 685. 
night, 448. 
reflex, 449. 
spasmodic, 449. 
useless, 449. 
whooping, 487. 
Coughs of reflex origin, 448. 
Counter-irritants, 462. 

Cow, breed of, best adapted for infant feed- 
ing, 99, 101; age of, 100. 
Ayrshire, 101; Devon, 100; Durham or 
Shorthorn, 100; Holstein-Friesian, 101. 
care of, 102. 

time and stage of milking, 100. 
Cows' milk, albuminoids in, 121. 
care of, 102. 
properties of, 63. 
Coxitis (see Morbus Coxarius), 898. 
Cranio-tabes, a symptom in rickets, 346. 
Cranium (see Skull). 
Cream, bacteria in, 136. 
Biedert's mixtures, 134. 
condensed, 191. 
dipper, 132. 
estimation of, 131. 
for home modification, 131. 
gauge, 118. 
how to procure, 131. 
mixtures, 133. 
pasteurization of, 132. 
ripening of, 135. 
Crede's method of preventing ophthalmia 
neonatorum, 863. 
ointment, in scarlet fever, 671; tubercular 
meningitis, 823. 
Cretinism, 760; diagnosis, 762; etiology, 760; 
pathology, 760; prognosis and course, 
771; symptoms, 760; treatment, 771. 
thyroid implantation in, 772. 
Crisis, in pneumonia, 507, 508; blood, 508. 
Croup, catarrhal, 444; symptoms, 444; prog- 
nosis, 445; treatment, 445; emetics, 444, 
447; steam inhalations, 446. 
kettle, 447; spasmodic, 444. 
Croupous, enteritis, 279. 
oesophagitis, 234. 
proctitis, 329. 
stomatitis, 226. 
tonsillitis, 432. 
Cry, as diagnostic aid, 13. 
from earache, 13; from hunger, 13. 
in cerebral disease, 13; in croup, 13; in 
marasmus, 13; in pneumonia, 13; in 
tubercular peritonitis, 13. 
Cryptorchidism, 399. 
Cupping, dry, 938. 
in bronchial asthma, 455. 



INDEX. 



955 



Cupping (concluded). 

in broncho-pneumonia, 462; in dry pleurisy, 

464; in hematuria, 417; in influenza, 485; 

in meningitis, 831; in severe dyspnoea of 

lobar pneumonia, 512; in paralysis, 814. 

Curvature of the spine, 897. 

Cutaneous tuberculin reaction, 533. 

Cyanosis, in acute tuberculosis, 530; in bron- 
chial asthma, 455; in broncho-pneu- 
monia, 458; in diphtheria, 581, 584; in 
hydropericardium, 378; in pulmonary 
tuberculosis, 538. 
of nails, in malarial fever, 714. 

Cyclic vomiting, 259. 

Cyclops, 81S. 

Cyst, congenital, of kidney, 58. 

Cystitis, acute, 420; etiology, 421; symptoms, 
421; treatment, 421; chronic, 421; prog" 
nosis, 422; symptoms, 421; treatment, 
422. 

Deafness, ao symptom, 435; caused by pres- 
ence of adenoids, 439; following measles, 
639; following meningitis, 831; scarlet 
fever, 661; with hypertrophy of tonsils, 
435. 
Decomposition, 356. 
Decubitus, 609. 
Deformities, congenital, 53. 

in rachitis, 341, 354. 
Degeneration, reaction of, 779. 
Delirium, in meningitis, 826. 
Dentition, 5; symptoms, 5; treatment, 6. 
before birth, 7. 
delayed, 7. 
difficult, 6. 

eruption of first teeth, 7. 
in cretinism, 760; in rachitis, 5. 
of first teeth, 7; permanent teeth, 7. 
Depressed sternum, 57. 
Descensus ventriculi, 256. 

Desquamation, following antitoxin rash, 556. 
in measles, 633; in rubella, 625; in scarlet 
fever, 648, 649; in variola, 682. 
Development, arrest of, in idiocy, 846; mental, 
in cretinism, 760. 
of the body, 5; of the infant, 1; of the vari- 
ous senses, 2, 3. 
Diabetes insipidus, 416. 

Diabetes mellitus, 419; prognosis, 419; symp- 
toms, 419; treatment, 419. 
following pertussis, 489. 
Diacetonuria, 415. 

Diagnostic points in auscultation, 450; breath- 
ing, 450; resonance, percussion, 450 
vocal, 450; rhythm, 450. 
suggestions, 9; cry, 13; eye aphorisms, 12 
gestures, 13; pulse-rate, 10; respiration 
11; sleep, 14; temperature, 11; throat 
13; tongue, 13; x-ray, 14. 
Diaphoretics, hot air bath, 666; hot pack, 665 
hot saline injections, 667. 
oiled silk jacket, 514. 
Diaphyses, in scurvy, 237. 
Diarrhoea, 273; causes, 273; treatment, 274. 



as a symptom of disease, 274. 

complicating measles, 640; scarlet fever, 660. 

fat, 266. 

in diphtheria, 553, 560; in malarial fever, 
714; in syphilis, 719; in typhoid, 693, 697. 

nervous, 274. 
Diastase, 155; test for, 250. 
Diastatic enzyme, in human milk, 59; in in- 
testinal contents, 69; in stoor of nurs- 
ling, 69. 
Diastolic murmurs, 367. 
Diazo reaction, in tuberculosis, 530; in urine, 

923. 
Diet (see also Feeding). 

from 1 year to 15 months, 153; from 18 
months to 3 years, 153; from 3 years to 
10 years, 153; articles allowed, 154; arti- 
cles forbidden, 154. 

in acute gastric catarrh, 246; in auto-intoxi- 
cation, 319; in chlorosis, 739; in constipa- 
tion, 291; in diarrhoea, 274; in diphtheria, 
576; in dysentery, 282; in gastritis, 
chronic, 142, 253; in gastro-duodenitis, 
252; in intestinal indigestion, acute, 397; 
chronic, 298; in lithaemia, 751; in milk 
infection, acute, 303; in pleurisy with 
effusion, 466; in pyelitis, 413; in rachitis, 
254; in rheumatism, 744; in scarlet fever, 
667, 668; in scurvy, 336; in tonsillitis, 
431; in tuberculosis, 534; in typhoid, 
700; in ulcer of the stomach, 259. 

of a nursing mother, 77, 79; of a wet nurse, 
86. 

salt free, 667. 
Dietary, 905. 

Diffuse cellulitis, in scarlet fever, 655. 
Digestive system, diseases of, 222. 
Dilatation of the stomach, acute, 254; diag- 
nosis, 255; etiology, 254; pathology, 255; 
prognosis, 255; symptoms, 255; treat- 
ment, 253. 

in chronic gastritis, 252. 
Diphtheria, acute, 539. 

bacillus, 539, 541, 544; differential stain, 540. 
in bronchitis, 452. 
true and false, 545. 

Klebs-Loeffler, 541; characteristics of, 
543; growth on blood serum, 544. 

bacteriology, 541; mixed infection, 573; 
mode of infection, 539, 543. 

chronic, 617; diagnosis, 618; isolation, 618; 
prognosis and course, 618; treatment, 
618. 

complications, 558. 
anaemia, 561. 
aphasia, 559. 
broncho-pneumonia, 559. 
cerebral thrombosis, 559. 
convulsions, 559. 
diarrhoea, 560. 
embolism, 559. 
empyema, 559. 
endocarditis, 559. 
enteritis, 561. 
gastritis, 560. 



956 



INDEX. 



Diphtheria (concluded), 
haemophilia, 559. 
haemorrhages, 559. 
heart, 559. 
measles, 640. 
meningitis, 559. 
mumps, 559. 
myocarditis, 559. 
nephritis, 560. 
omphalitis, 33, 551, 560. 
otitis, 559. 
paralysis, 560, 577. 
pleurisy, 559. 
scarlet fever, 652, 661. 
course, 550, 563. 

diagnosis, 556; bacteriological, 557; how to 
take a culture, 557; premembranous 
stage, 558. 
differential diagnosis from catarrhal angina, 
558. 
peritonsillar abscess, 558. 
thrush, 558. 

tonsillitis, ulcerative, 558; follicular, 558. 
etiology, 539. 
extubation in, 613. 
follicular forms, 554. 
immunization in, 566. 
intubation in, 579. 
isolation, 565. 
local, 551. 

nasal, 551; symptoms, 551. 
pathology, 546; blood, 548; haemorrhages, 
548, 559; lesions, 546; lymph nodes, 548; 
membrane, 546. 
predisposing factors, 539. 
prognosis, 464. 
prophylaxis, 564. 

pseudo or false, 540, 619; mortality, 621. 
septic, 553. 
symptoms, 550. 

toxin, effect of, on nervous system of ani- 
mals, 549; on heart, 550. 
tracheotomy, 615. 

treatment, antitoxin, 570; dietetic, 575; 
hygienic, 560; medicinal, 576; modern, 
569. 
Diphtheria antitoxin, dose required, 571. 
dry, 571. 

immunizing dose, 566. 
indications for second and third injections, 

572. 
influence of, on mortality, 577. 
in treatment of membranous ophthalmia, 

846. 
limitations of, 567. 
manner of administering, 570. 
rashes, 555; desquamation following, 556; 

site of eruption, 556. 
result, general, 567; with and without, 582. 
Diphtheritic colitis, 278, 279. 
conjunctivitis, 863. 
dysentery, 279. 
oesophagitis, 234. 
omphalitis, 33, 551. 



paralysis, 561, 563; simulating anterior 

poliomyelitis, 563. 
rhinitis, 550. 
stomatitis, 226. 
Diphtheroid, 618. 
Diplegia, haemorrhage causing, 778. 

spastic, 834. 
Diplo-bacillus of Morax, 862. 
Diplococcus, Fraenkel, in broncho-pneumonia, 
457; in lobar pneumonia, 498. 
pneumoniae, 457; stain for, 929. 
in broncho-pneumonia, 457; in pleurisy 

with effusion, 464. 
intracellulars, 827. 
Disease, diagnosis of, 10, 12. 
peculiarities of, 9. 
symptoms of, 9, 12. 
Disinfection, 934. 
as a means of prevention, 934. 
in diphtheria, 564; in infectious diseases, 
934; in pertussis, 489; in scarlet fever, 
664; in typhoid, 700; in variola, 685. 
of clinical thermometers, 934; of hands, 934; 
of sputa. 935; of urine and faeces, 935; 
of water closets, 935. 
Dislocation of the hip, congenital, 899. 
Displacement of the heart, 15, 884. . 
liver, 382. 
spleen, 386. 
stomach, 256, 258. 
Diverticulum, Meckel's, 35. 
Doboll's solution, 427. 
Dropsy (see also (Edema and Anasarca), of 

the feet, in leukaemia, 736. 
Drug eruptions resembling measles, 640. 
Drugs, administration of, 936; per rectum, 939. 
dosage of, 044. 

effect of, on woman's milk, 73. 
in treatment of constipation, 291. 
Dry cupping, 938 (see also Cupping). 
Dry pleurisy, 463. 
Dry-tap in lumbar puncture, 830. 
Ductless glands, diseases of, 760. 
Ductus arteriosus Botalli, 370; closure of, 362. 
Duke's disease, 674; period of incubation, 
674; prognosis, 675; symptoms, 674; treat- 
ment, 675. 
Duodenal bucket, 248, 249. 

catarrh, 397. 
Dura mater, inflammation of, 833. 
Dysentery, 278; bacteriology, 279; diagnosis, 
282; pathology, 278; prognosis, 282; symp- 
toms, 281; treatment, 282; diet, 282. 
fever curve in, 280; amoebic, 278; diphthe- 
ritic, 279. 
Dyspepsia, 242. 
Dyspeptic asthma, 260. 

Dyspnoea, in broncho-pneumonia, 461; in 
croup, 445; in dilatation of stomach, 255; 
in diseases of thymus, 773; in dry 
pleurisy, 464; in hydroperiearilium, 378; 
in lobar pneumonia, 512; in papillomata, 
888; in pulmonary tuberculosis, 538; in 
retro-pharyngeal abscess, 443; in toxic 



INDEX. 



957 



Dyspnoea (concluded). 

scarlet fever, 650; in tuberculous pneu- 
monia, 515. 
oxygen in, 513. 

Dysuria, 92L 

Ear, diseases of, 854. 
foreign bodies in, 860. 
syringe, 856. 
Earache, in diphtheria, 553 ; in scarlet fever, 668. 
Ears, bleeding from, in diphtheria, 559. 
in diphtheria, 553, 559; in scarlet fever, 668. 
inflammation of, in otitis, 854. 
running, in syphilis, 723. 
Eberth's typhoid bacillus, 689, 690. 
Ecchymoses, in purpura, 747; in purpura 

hemorrhagica, 748; in scurvy, 337. 
Eclampsia (see Convulsions), 781. 

in epilepsy, 802. 
Ectogenous streptococcus infection, 702. 
Ectopia vesica? congenitalis, 413. 
Eczema, 809; etiology, 869; symptoms, 869; 
treatment, 870. 
associated with chronic gastritis, 253. 
bathing in, 870. 
in lithsemia, 751. 
intertrigo, 871. 
rubrum, 870. 

to relieve excoriation of, 149. 
tubercle germs in pus from, 519. 
Effusion, in ascites, 393; in hydrocephalus, 
814; in nephritis following scarlet fever, 
666; in pericarditis, 376; in pertussis, 
489; in pleurisy, 465. 
Eggs, nutritive value of, 210. 
Elbow-joint disease, 902. 

Electricity, in cerebral paralysis, 839: in 
chorea, 790; in constipation, 290; in 
enuresis, 424. 
Emaciation, in dilatation of stomach, acute, 
255; in gastritis, chronic, 253; in hydro- 
cephalus, 815: in myelitis, acute, 806; in 
tuberculosis, chronic, 538. 
Embolism, in endocarditis, 373; in diphtheria, 

559. 
Embolus, in endocarditis, 373. 
Emetics, in bronchitis. 454: in croup, 447: in 
dyspnoea of broncho-pneumonia, 461; in 
gastric catarrh, 244. 
Emphysema, complicating diphtheria, 580; 

pertussis, 489. 
Empyema, 466; bacteriology, 467; course, 468; 
etiology, 466; pathology, 467; prognosis, 
468; symptoms, 467; treatment, 469; 
surgical, 469; anaesthetic, 469. 
chronic, 470. 
complicating measles, 639; scarlet fever, 

660; diphtheria, 559. 
following pertussis, 489; pleuro-pneumonia, 

502. 
James apparatus for expanding the lungs 

in, 470. 
of the mastoid antrum, complicating scarlet 

fever, 654. 
tubercular, 471. 



Enanthero, in scarlatina sine angina, 652; in 

scarlet fever, 647; in measles, 631. 
Encephalocele, 817. 
Enchondromata. 887. 

Endocarditis, 371; diagnosis, 373; etiology, 372; 
pathology, 373; prognosis and course, 
373; symptoms, 372; treatment, 374. 
complicating chorea, 788; diphtheria, 559; 

rheumatism, 742. 
following scarlet fever, 661; typhoid, 698. 
malignant, 374; diagnosis, 375; pathology, 
374; prognosis and course, 375; symp- 
toms, 375; treatment, 375. 
Enemata (see also Rectal Irrigations), 
continued use of, 289. 
how to give, 288. 

in chronic gastritis, 252; in constipation, 
288; in dysentery, 281; in intestinal colic, 
295. 
nutrient (see Rectal Feeding), 
oxgall, 252. 
Enteralgia, 293. 
Enteritis, croupous, 279. 
membranous, complicating diphtheria, 561. 
tuberculous, 519. 
Enuresis, 422. 

a symptom of lithaemia, 751. 

causes, 422; adenoids, 423, 439; tight 

prepuce, 423. 
faulty metabolism, 333. 
in meningitis, 826. 
prognosis, 423. 

treatment, 423; mechanical, 423; elec- 
trical, 424. 
diurna, 422. 
nocturna, 422. 
Enzymes, 127. 

Eosinophiles, in pneumonia, 729; in scarlet 
fever, 729; in skin diseases, 728; in 
syphilis, 728. 
Epidemic catarrhal fever, 479. 
cerebro-spinal meningitis, 824. 
hysteria, 792. 
Epilepsy, S01. 

aura in, 803. 

differential diagnosis, 804; from hysteria, 

804. 
etiology, 801. 

following convulsions, 801. 
pathology, 802: intestinal putrefaction, 

803; urine, 803. 
predisposing factors, 801. 
prognosis and course, 804. 
symptoms, 803. 

treatment, 804; operative, 805. 
grand mal form, 803. 
idiopathic, 802. 
petit mal form, 803. 
Epiphyses, in rachitis, 348; in syphilis, 724. 
Epiphysitis, acute, 903. 
Epispadias, 399. 

Epistaxis, in haemophilia, 752; in measles, 642: 
in pertussis, 489; in pulmonary tuber- 
culosis, 538; in septic diphtheria, 554; 



958 



IXDEX. 



Epistaxis (concluded). 

in thrombosis of cerebral sinuses, 860; 
in toxic scarlet fever, 650. 
Epithelial desquamation of the tongue, 231; 

treatment, 232. 
Erb's paralysis, 40. 

Eructations, in chronic gastritis, 253; in gas- 
troptosis, 256. 
of gas from excess of sugar, 121. 
sour, in intestinal indigestion, 296. 
Eruption, artificial, 19. 
drug, resembling measles, 640. 
following injection of diphtheria antitoxin, 

555. 
in chloasma, 873; in erythema infectiosum, 
674; in influenza, 480; in measles, 630, 
632; in meningitis, 826; in rubella, 624; 
in scabies, 883; in scarlet fever, 649; in 
stomatitis aphthosa, 223, 224; in syphilis, 
720; in typhoid, 695; in vaccinia, 688; in 
varicella, 676; in variola, 681. 
Erysipelas, 702. 

blood in, 728. 
complications, 704. 
etiology and bacteriology, 702. 
pathology, 703. 
prognosis, 704. 
treatment, 705. 
migraine, 703. 
Erythema, 871. 

differentiated from syphilis, 720, 871. 
following injection of diphtheria anti- 
toxin, 555. 
on buttocks, 871. 
Erythroblasts, 728. 
Erythrocytes, 726; in syphilis, 728. 
Eskay's albuminized food, 200; analysis of, 

201. 
Estlander's operation in chronic empyema, 

471. 
Ether as an anaesthetic, 931. 
Ethylchloride, 931. 
Eucasin, 205. 

Eustachian tube, in adenoid vegetations, 438; 
in otitis media, 854. 
inflammation of, in rhinitis, 426, 333. 
Examination of heart, 362; of lungs, 450; of 

patient, 9. 
Exercise, 23 (see also Gymnastics). 

in constipation, 289; in lithaemia, 751. 
Exophthalmia in thrombosis of cerebral 

sinuses, 860. 
Exophthalmic goiter, 772; prognosis, 772; 
symptoms and diagnosis, 772; treatment, 
772. 
Exophthalmus, in exophthalmic goiter, 772. 

in hydrocephalus, 816. 
Expectorants, in broncho-pneumonia, 462. 
Expectoration (see Sputum), 
in bronchitis, 453; in pulmonary tubercu- 
losis, 538; in ulcer of stomach, 258. 
Exploratory puncture, in empyema, 467; in 
pleurisy with effusion, 465. 
points to be noted in making, 467. 
Exstrophy of the bladder, 416. 



Extubation, 613. 

auto, 596, 
Eye, as a diagnostic aid, 12. 

diseases of, 861. 

in chlorosis, 738; in chorea, 787; in distin- 
guishing the still-born from the dead, 
43; in dysentery, 282; in exophthalmic 
goiter, 772; in gonorrheal infection, 402; 
in measles, 630, 639; in meningitis, 823, 
826; in nystagmus, 785; in stomatitis 
gangrenosa, 227. 

prophylaxis and treatment of, in the new- 
born, 32. 

suffusion of, in rubella, 623. 
Eyelid, in blepharitis, 866; in hordeolum, 
867; in purulent ophthalmia, 863; in 
trachoma, 866. 

method of everting, 867. 

proptosis of, in scurvy, 337. 

Face, cyanosis of, in broncho-pneumonia, 458. 
in adenoid vegetations, 438; in chlorosis, 
738; in cretinism, 760, 762; in diphtheria, 
septic, 553; in nephritis, 407; in pertussis, 
488. 
Facial paralysis, following mastoid operation, 
842; retro-pharyngeal abscess, 842. 
in the new-born, 842; prognosis and course, 
842; treatment, 842. 
Faecal vomiting, 320. 
Faeces (see Stools). 
Fainting (see Syncope). 

in leukaemia, 736. 
Fat, absorption of, 262; determination of, 
117; cream gauge, 118; Feser's test, 118; 
Marchand's test, 118. 
in breast milk, 87; to decrease, 87; to in- 
crease, 87. 
in cows' milk, 116; excess of, 116. 
in stool, 116. 
metabolism, 116. 
Fatty degeneration, of blood-vessels, 835; of 
newly born, 50; in pernicious anaemia, 
734. 
growths, 887. 
heart, 366. 
liver, 383, 384. 
Faulty metabolism, 332. 
lientcric stools, 332. 
scybalous stools, 332. 
catarrhal tendencies, 333. 
nervous manifestations, 333. 
treatment. 333. 
Feeble-mindedness (see Idiocy and Imbecil- 
ity), 845. 
Feeding (see also Diet and Gavage). 
bottle or hand, 139. 

general rules for, 139. 
utensils required, 139. 
breast, 71. 
buttermilk, 182. 
caloric method of, 166. 

Casselberry method of, in intubation, 595. 
cows' milk, 139. 
cream, 131. 



TXDEX. 



9.i9 



Feeding (concluded). 

flour-ball. 77. 

from 1 year to 15 month?, 90. 

goats* milk. 1^2. 

in acute milk infection, 303; in athrepsia, 
359; in atrophy and chronic gastritis, 
142, 253; in bronchitis, 454; in cleft 
palate, 54; in diphtheria, 575: in dys- 
pepsia, 147: in hypertrophic pyloric 
stenosis, 251: in intubated cases, 594: in 
milk idiosyncrasies, 168: in myocarditis. 
3S0; in pertussis, 490: in pneumonia, 514; 
in starvation and rickets, 144. 

intervals of, 139. 

mixed, 72. 

modified milk, 173. 

of delicate or sick children. 155; of prema- 
ture infants. 28. 

rectal, 454, 576. 

substitute, 156. 
Feeding bottles, 165: care of, 157. 
Feeding cup, 91. 
Femur in rachitis, 348. 
Ferment tests — steapsin. trypsin, amylopsin, 

249. 
Fermentation in chronic gastritis, 252. 

in auto-intoxication, 319. 

test in urine, 927. 
Ferments, and their actions, 23$. 

unorganized. 237. 
Feser"s lactoscope, 118. 
Fever, 472 (see also Temperature). 

causes of, 472. 

hay, 455. 

how to reduce, 511. 

hysterical, 474. 

in faulty metabolism, 333. 

in gastric catarrh, 247. 

in tonsillitis, 431. 
Fingers in cretinism, 760. 
First attempts at -walking. 2. 
Fischer's corrugated rubber intubation tubes, 

5S5. 
Fissure of the anus, 328. 
Fistula in alveolar abscess, 233. 
Flatfoot, 896. 

Flatulence in gastro-duodenitis, 250. 
Flaxseed poultice, 937. 
Flexner anti-meningitis serum. 831. 
Flour-ball feeding, 77. 
Focal necrosis, 384. 
Feetal (see also Congenital) circulation, 361. 

ichthyosis, 46. 

typhoid, 691. 
Fcetus. in syphilis, 716. 
Follicular forms of diphtheria, 554. 

tonsillitis, 431: resembling diphtheria, 558. 
Fomentations, 937. 
Fontanel, 775. 

anterior, 775. 

in cretinism, 760; in hydrocephalus, 815; in 
rachitis, 341, 346. 

posterior, 775. 

premature closure of, 775. 



Food, dextrinized, 155: method of preparing, 

155. 
Foods, infant. 194. 
patent, 193: composition of, as compared 
with human milk. 2"4. 
Foot and mouth disease (see Stomatitis Aph- 

thosa), 223. 
Foramen Magendie. in hydrocephalus. 778. 

ovale, closure of. 362. 
Foreign bodies in ear. $60: larynx, 44S; nose, 

429: oesophagus. 235. 
Formaldehyde in milk. 912: test for. 912. 
Formula? for bottle-fed infants, 140. 141. 
Fourth disease (see Erythema Infectiosum), 

674. 
Fractures, 40. 
green stick, 40. 
during labor, 40. 
in rachitis. 34$. 
Fraenkel diplococcus, in lobar pneumonia. 49$. 
Friedrich's disease (see Hereditary Ataxy). 
SOS. 
sign, in chronic pericarditis, 377. 
Fright, causing chorea. 7$7: convulsions. 7S1. 
Furuncle, $77. 
differential diagnosis from carbuncle. B77. 
in rachitis, S77: in syphilis. 720. 
Furunculosis, complicating scarlet fever, 660. 

Gaertner mother milk. 188. 
Gall-bladder, congenital absence of, 35. 
Gangrene. $$1. 
complicating erysipelas, 703; pneumonia, 

509; scarlet fever, 66*): typhoid. 698. 
of cheeks, 227; of genitals, 22$; of mouth, 

698. 
pulmonary, 462; diagnosis, 462; treatment, 

463. 
symmetrical. SS3. 
traumatic, 881. 
Gastric catarrh, 242: pathology, 243; prog- 
nosis and course, 243: symptoms, 243: 
treatment, 244. 
contents, examination of, 915. 
fever, resembling typhoid, 698. 
juice, chemical constituents of. 236. 

influence of, on pathogenic germs. 237. 
238. 
Gastritis, acute, 242. 

complicating diphtheria, 560. 
chronic. 252: diagnosis, 253: pathology _". 
predisposing causes, 252: prognosis and 
course, 253: symptoms. 252; treatment, 
253. 
Gastrodiaphane for translumination of stom- 
ach. 255. 
Gastro-duodenitis, 252: symptoms, 252: treat- 
ment, 252. 
Gastro-enterostomy in spasm of the pylorus. 

248, 250. 
Gastro-intestinal disturbance, causing asth- 
matic attacks.. 455. 
haemorrhage, 38. 
tract, in syphilis, 719. 



960 



INDEX. 



Gastroptosis, 256; diagnosis, 257; etiology, 256: 
prognosis and course, 258; symptoms, 
256; treatment, 258. 
Gavage, apparatus for, 29. 
in cleft palate, 54; in intubated cases of 

diphtheria, 594. 
method of, in premature infants, 30. 
Ge-latine food, 908. 
General hygiene of the infant, 16. 
Genital organs, diseases of, 395. 
irritation in chronic cystitis, 421; in phi- 
mosis, 397. 
Genu recurvatum, 355. 

varum (see Bowlegs), 355. 
Geographical tongue (see Epithelial Desqua- 
mation), 231. 
German measles, 622. 
Gestures as diagnostic aid, 13. 
Ginger poultice, 938. 
Gingivitis, 6; in scurvy, 337. 
Gland, thymus, 753. 

thyroid, 760. 
Glands, adrenal, 774. 
bronchial, in broncho-pneumonia, 459. 

enlarged, causing bronchial asthma, 455. 
cervical, 333; causing torticollis, 747. 

in stomatitis gangrenosa, 228. 
diseases of, 753. 

in adenitis, 754; in eczema, 869; in leukae- 
mia, 735; in mumps, 757; in rubella, 
623; in status lymphaticus, 75:!; in scar- 
let fever, 647. 
peripheral, in acute tuberculosis, 530. 
submaxillary, in diphtheria, 551, 553; in 
scarlet fever, 647. 
Glomerulo-nephritis, 405. 
Glossitis, 232. 

Glottis, oedema of, in erysipelas, 704; in scar- 
let fever, 671; in variola, 685. 
spasm of, causing cough, 448. 
Glucose in urine, 925. 
Glycogenic reaction of blood, 730. 
Glycosuria, 418. 
in diabetes mellitus, 419; in pseudo-hyper- 
trophic paralysis, 920. 
Goats' milk, 182. 
Goiter, exophthalmic, 772. 

wet-nurse with, 81. 
Gonococcus, 401; in cystitis, 421; in gonor- 
rhceal vaginitis, 401. 
stain for, 929. 
Granular gastritis, 252. 
ophthalmia, 864; from false or follicular 
granulation, 865. 
Granuloma, 33. 
Granulomata, 889. 

Graves' disease (see Exophthalmic Goiter), 
772. 
sign in bronchitis, 453. 
Grippe (see Influenza), 479. 
Growing pains, 741, 743. 
Growth and height, 5. 

in diabetes insipidus, 416. 
Growths (see also Tumors), abnormal, 884. 



Gums, bleeding, in purpura haetnorrhagiea, 
748. 

inflamed, 6; possible source of invasion of 
tubercle bacilli, 518. 

in scurvy, 337: in stomatitis gangrenosa, 
228; in toxic scarlet fever, 660. 
Gymnastics (see also Exercise), 23. 

in lateral curvature of the spine, 897. 

pulmonary, in empyema, 470; in tubercu- 
losis, 535. 

Habit-spasm, differential diagnosis from true 

chorea, 788. 
Haernatoma of the sterno-mastoid, 57. 
Hagmaturia, 417; prognosis, 417; treatment, 
418. 
in cystitis, 421; in malarial fever, 714; in 
purpura haemorrhagica, 748; in pyelitis, 
414; in scurvy, 336; in symmetrical gan- 
grene, 883. 
Haemiplegia (see Paralysis, Cerebral), 834. 
Haemoglobin, at birth, 727. 

in rachitis, 728; in diphtheria, 549. 
Haemoglobinuria, 418. 
in malarial fever, 720; in symmetrical gan- 
grene, 883; in syphilis, 920"; in Winckel's 
disease, 920 
neonatorum, 50. 
paroxysmal, 418. 
Haemophilia, 751; pathology, 751; prognosis, 

752; symptoms, 752; treatment, 752. 
Haemoptysis, in chronic tuberculosis, 538; in 

purpura haemorrhagica, 748. 
Haemorrhage, cerebral, in pertussis, 489. 
following adenoid operation, 442; operation 
for peritonsillar abscess, 434; tonsil- 
lotomy, 435. 
gastro-intestinal, 38; serum injection in, 39. 
in congenital obliteration of the bile duct, 
36; in diphtheria, 554, 559; in exoph- 
thalmic goiter, 772: in leukaemia, 735; in 
pachymeningitis, 833; in syphilis, 719; in 
typhoid, 697. 
from bowels, 736; genital tract, 417"; kidney. 

417; stomach, 736. 77l'. 
internal, in typhoid, 697. 
into subarachnoid space, 778. 
spontaneous, 37. 
subcutaneous, in scurvy, 337. 
umbilical, 38.' 
Haniorrhagic diseases of the newly born, 37. 
Haemorrhoids, 29. 
Hair, 1; in cretinism, 760. 
Hand-feeding (see Bottle Feeding), 139. 
Hands, disinfection of, 934. 

in cretinism, 762. 
Harelip, 54. 
nipple, 54. 
Hay-fever, 455; resembling bronchial asthma, 

455. 
Head, circumference of, at birth, 775. 
in hydrocephalus, 815; in rachitis, 341. 
nodding, in spasmus nutans, 785. 
retraction of, Jn cerebro-spinal meningitis, 
826; in influenza, 4S2. 



INDEX. 



961 



Head (concluded), 
shape of, 775, 776. 
supplementary, 58. 
sweating, 346. 
Headaches, 784. 
due to brain lesions, 785; to general sys- 
temic conditions, 784; to local origin, 
784; to influenza, 480. 
in chlorosis, 738; in chronic gastritis, 253; 
in diabetes insipidus, 416; in lithaernia, 
751; in tubercular meningitis, 823. 
reflex, 784. 

sick (see Migraine), 785. 
Heart and foetal circulation, 361. 
classification of cardiac diseases, 365. 
diagnostic points, 366. 
diseases of, 366; classification of, 365. 
displacement of, 17, 884. 
examination of, 363; area of dullness, 364, 

369; location of apex beat, 362. 
fatty, 366. 

in chorea, 789; in diphtheria, 552, 553; in 
gonorrhceal infection, 402; in pertussis, 
489; in rheumatism, 742; in scarlet 
fever, 659, 665. 
murmurs, 366; anaemic, 367; diastolic, 367; 
pericardial, 368; systolic, 366; venous, 
368. 
palpitation of (see Tachycardia), 366. 
position of, 363. 
primary tuberculosis of, 519. 
reflex symptoms of, 366. 
size of, 362. 

sounds and murmurs, 366. 
tension, 363. 

tricuspid insufficiency, 367. 
weight of, bt»2. 
Heat-stroke (see Insolation), 851. 
Hehner's test for formaldehyde in milk, 913. 
Height, from birth to twentieth year, 5; of 

new-born, male, 5; female, 5. 
Hemichorea, 788. 
Hemicrania (see Migraine), 785. 
Hemiplegia (see Cerebral Paralysis), 834. 
complicating diphtheria, 559. 
haemorrhage into subarachnoid space caus- 
ing, 778. 
Hemostatics in acute tuberculosis, 535. 
Hepatic abscess, caused by wofms, 325. 
Hereditary ataxy, 808. 

syphilis, 723. 
Hernia, 395; diagnosis, 396; from hydrocele, 
396; causes, 395; prognosis, 396; symp- 
toms, 396; treatment, 396; surgical, 397. 
following pertussis, 489. 
in the new-born, 395. 
umbilical, 325; truss, 323. 
Herpes, circinatus, 878. 
tonsurans, 878. 
zoster, 873. 
Hiccough (see Singultus). 
Hinged bucket for extracting foreign bodies, 

235. 
Hip, congenital dislocation of, 899; etiology, 
899; symptoms, 900; treatment, 900. 



bilateral dislocation, 900. 

unilateral dislocation, 900. 
Hip-joint disease (see Morbus Coxarius), 898. 

from perinephritis, 410. 

tubercular, 898. 
Hips, in lateral curvature of the spine, 897. 
Hives (see Urticaria), 871. 
Hoarseness, in syphilis, 723. 
Hodgkin's disease, 757. 
Home modification of milk, 139. 
Hordeolum, 867. 
Horismascope, 922. 
Horlick's lunch tablets, 153. 

malted milk, 196; analysis of, 196. 
Hot air bath, 666. 

compresses or fomentations, 937. 
Hot and cold bath, in asphyxia neonatorum, 

44. 
Human milk (see Milk, Woman's). 

diastatic enzyme in, 69; new reaction of, 
69; properties of, 62. 

to preserve, 70. 
Humanized milk, 203, 909. 
Hutchinson's teeth, 720. 
Hydrencephalocele (see Meningocele), 817. 
Hydrencephaloid, 342. 
Hydrocele, 397. 

Hydrocephalus, 814; etiology, 814; pathology, 
814; prognosis and course, 815; symp-. 
toms, 815; treatment, 815. 

external, 814. 

foramen Magendie in, 778. 

internal, 814. 

intra-uterine, 817. 
Hydrochloric acid, function of, in stomach, 
237. 

in gastric contents, 915. 

test for formaldehyde in milk, 913. 
Hydropericardium, 378; pathology, 378; treat- 
ment, 378. 
Hygiene, of infant, 16; fresh air, 20; proper 
training, 22. 

of mouth, 16. 

nervous system, 23. 

stable, 109, 110; cows, 110; milk, 110; milker, 
110. 
Hyperaemia, cerebral, in insolation, 852. 
Hyperaesthesia, in acute myelitis, 806. 

in multiple neuritis, 794. 
Hyperorexia (see Bulimia), 255. 

in acute tuberculosis, 530. 
Hyperthyrea (see Exophthalmic Goiter), 772. 
Hypertrophic pyloric stenosis, 250; etiology, 
250; morbid anatomy, 250; prognosis, 
251; treatment, 251. 

gastroenterostomy in, 251. 

tonsillitis, 432; etiology, 435; symptoms, 435; 
treatment, 436. 
Hypertrophy of muscles, 842; of tongue, 232; 

• of tonsils, 434. 
Hypodermic medication, 943, 944. 

in spasmodic laryngitis, 447. 
Hypodermoclysis, in scarlet fever, 666. 

in typhoid, 699. 
Hypospadias, 399. 



962 



IXDEX. 



Hysteria, 791; diagnosis, 791; differential diag- 
nosis, 804; from epilepsy, 804; pathology, 
791; prognosis and course, 792; treat- 
ment, 792. 
epidemics of, 792. 



Ice-bag, throat, 431, 434. 

coil, in tubercular meningitis, 823'. 
Ice cream, 212. 
Ichthyol ointment, 871. 
Ichthyosis, fcetal, 46. 
Icterus, 381; urine in, 918. 

complicating pseudo-leukaemic anaemia, 
737; scarlet fever, 660. 
neonatorum, 48. 
Idiocy, 845; diagnosis, 846; etiology, 845; 
pathology, 850; symptoms, 850; treat- 
ment, 850. 
congenital, 846. 

infantile amaurotic family, 849. 
Mongolian, 846. 
Ileo-colitis (see Dysentery), 278. 
Imbecility, 845. 

Immunity conferred by woman's milk, 69. 
Immunization in diphtheria, 566. 
Imperforate rectum, 59. 
Imperial granum, 199; analysis of, 199. 
Impetigo, 874; symptoms, 874; treatment, 875. 

resembling varicella, 678; variola, 683. 
Improper nutrition, 332. 
Inanition, in athrepsia infantum, 357; in 

chronic gastritis, 253. 
Incubators, 25, 31. 
Indican, in tuberculosis, 530. 

test for, in urine, 925. 
Indicanuria, 332, 415. 

Indigestion, acute intestinal, 296; prognosis, 
297; symptoms, 296; treatment, 297; diet, 
297. 
chronic intestinal, 297; diagnosis, 298; eti- 
ology, 297; prognosis, 298; symptoms, 
297; treatment, 298. 
Infancy and childhood, 1. 
Infant feeding, 61. 
foods, 194. 
stools, 263. 
Infantile atrophy, 356. 
spinal paralysis, 809. 
Infarctions, uric acid in kidneys, 918, 920. 
Infectious diseases, 472; table of, 476, 477. 
Inflamed gums, 6; treatment of, 6. 
possible source of invasion of tubercle 
bacilli, 518. 
Inflammation of the dura mater, 833. 
Inflammatory rheumatism (see Rheumatism), 

740. 
Inflation of bowel, in intussusception, 322. 
of lungs, 44. 

of stomach, in gastroptosis, 257. 
Influenza, 479. 

complications of, 476, 482; empyema, 482; 
nephritis, 482; neuritis, 482; otitis, 
482. 
course, 482. 



diagnosis, 480; from measles, 480; scar- 
let fever, 480; typhoid, 480. 
duration, 476. 
eruption, 480. 
isolation, 476. 
prognosis, 482. 
symptoms, 476, 480. 
treatment, 483. 
gastro-enteric type, 481. 
nervous type, 482. 
respiratory type, 481. 
Inhalations, in asthma, 456; in bronchitis, 
454; in cerebral pneumonia, 505; in 
croup, 446," 447; in pertussis, 494; in 
tonsillitis, 431. 
Injections (see also Rectal Injections), 
intralaryngeal, 446. 
intravenous, in erysipelas, 705. 
of horse serum, 31, 39. 
subcutaneous, in scarlet fever, 666, 672. 
Insolation, 851; diagnosis from meningitis, 
851; pathology, 851; prognosis, 851; 
symptoms, 851; treatment, 852. 
Insomnia (see also Restlessness at Night), 
from use of coffee, 213. 

in cretinism, 764; in gastroptosis, 256; in 
hysteria, 792; in influenza, 481. 
Intermittent fever (see Malarial Fever), 706. 
Interstitial hepatitis, 384. 
Intertrigo eczema, 871. 

Intestinal colic, 293; causes, 293; diagnosis, 
294; symptoms, 293; treatment, 294. 
haemorrhage, 694. 

indigestion, acute, 296; symptoms, 296; 
treatment, 297. 
chronic, 297; diagnosis, 298; etiology, 297; 
prognosis, 298; symptoms, 297; treat- 
ment, 298. 
obstruction, from intussusception, 318; in 

constipation, 286. 
perforation, in typhoid, 693, 697. 
Intestines, 261; caecum, 262; course of colon, 
261; large, 261; length of, 261; sigmoid 
flexure, 262; abnormalities of, 286; small, 
262; transverse colon, 262; vermiform 
appendix, 262. 
absorption of fat in, 262. 
bacteria of, 268. 
formation of gas in, 262. 
haemorrhages from, 697, 772. 
perforation of, 697. 
physiology of, 262. 

ulceration of, in newly born, 284; tuber- 
cular, 538. 
Intracranial injections, 832. 
Intralaryngeal injections, 446. 
Intraspinal anaesthesia, 932; injections, 832. 
Intravenous injections, in erysipelas, 705. 
Intraventricular method of serum injection, 

828. 
Intubation, 579; false passage in, 592, 612. 
in aphonia spastica, 593. 
in cicatricial stenosis, 592; due to syphilis, 

irritants or traumatism, 592. 
in deformities of larynx, 593. 



INDEX. 



963 



Intubation (concluded), 
in diphtheria, 579. 

accidents during, 591; false passage in, 

612. 
after-effects of, 603. 
effect of, in upper-air passages, 597. 
feeding in, 594; Casselberry method, 595. 
indications for, 579. 
method of, dorsal, 586; O'Dwyer, 586; 

upright, 586. 
mortality, 593. 
results, 580, 581. 
in papilloma of larynx, 593. 
in pertussis, 489. 
Intubation instruments, 584. 
Fischer's corrugated rubber tube, 585. 
medicated tubes, 612. 

specially constructed rubber tubes, 585, 592. 
Intussusception, 319; diagnosis, 319; prog- 
nosis, 321; symptoms, 319; faecal vomit, 
319; treatment, 322; surgical, 322. 
colic, 319. 
ileo-colic, 319. 
ileo or jejunal, 319. 
Invagination of bowel (see Intussusception), 

318. 
Invertin, function of, 238. 
Iodophile reaction of blood (see Blood Reac- 
tion), 730. 
Iritis, in meningitis, 826. 
Irrigation (see also Rectal Irrigation), 
chamomile, in dysentery, 386. 
cold water, in constipation, 289. 
in vaginitis, 403. 
nasal, 671. 
of bladder, 420, 421; of colon, in typhoid, 

699. 
saline, in athrepsia, 360; in diarrhoea, 274. 
Ischio-rectal abscess, 329. 

Isolation, in diphtheria, 565, 618; in dysentery, 
280; in influenza, 476, 483; in measles, 
640; in mumps, 759; in pertussis, 389; 
in scarlet fever, 664; in syphilis, 724; 
in varicella, 678; in variola, 685. 
Itching, in scabies, 883; in scarlet fever, 664. 
in variola, 6&5. 



Jacket, pneumonia, 461, 462. 

James's apparatus for expanding the lung 

after empyema, 470. 
Jaundice (see also Icterus), 48, 381. 

catarrhal, 252. 
Jaw, in alveolar abscess, 233; in angina 
Ludovici, 233. 
in tetanus, 800. 

necrosis of, in stomatitis gangrenosa, 228. 
upper, in syphilis, 721. 
Joints, diseases of, 890. 
in gonorrhceal infection. 402; in haemophilia, 
752: in meningitis, 826; in purpura rheu- 
matica, 748; :n rheumatism, 741. 
scrofulous, 519. 
Junket, 908. 
Just's food, 202; analysis of, 202. 



Keller's malt soup, 170, 907; in athrepsia, 360. 
Keratitis, in measles, 639; in meningitis, 826. 
Kernig's sign, 826. 
Kidney, calculi in, 420. 
congenital cyst of, 58. 
dilatation of, 412. 
diseases of, 405. 
haemorrhage from, 417. 
inflammation of, 406. 
in new-born, 918; in pyelitis, 413; in scarlet 

fever, 656. 
position of, in infancy, 405. 
sacculation of, 412. 
Klebs-Loeffler bacillus, 539, 541. 
in diphtheritic omphalitis, 33; in measles, 
636; in membranous conjunctivitis, 863. 
smear preparation, 544. 
stain for, 929. 
Knee, in morbus coxarius, 898; in rachitis, 

342, 348. 
Knee-jerk (see Patellar Reflexes). 

in multiple neuritis, 794. 
Knee-joint disease, 901; diagnosis, 901; from 
rheumatism, 901; etiology, 901; path- 
ology, 901; prognosis, 902; symptoms, 
901; treatment, 902. 
in morbus coxarius, 898; in rachitis, 342. 
Knock-knee, in rachitis, 342, 348. 
Koplik's sign in measles, 632. 
Kyphosis, in Pott's disease, 890; in rachitis, 
347. 

Lab-ferment, 236. 
action of, on milk, 62, 63. 

Laboratory modification of milk, 173. 

Lachrymal duct, inflammation of, in nasal 
catarrh, 426. 

Lactalbumin, 121. 

Lactation, massage of breasts during, 95. 

Lactic acid, in buttermilk, 183; in gastric 
contents, 915; in stomach, 237; in urine. 
183. 

Lactic acid bacillus, 183, 314. 

Lactoscope, 118. 

Lactose, 119. 

La Grippe (see Influenza), 479. 

Lahmann's vegetable milk, 187. 

Laparotomy, in appendicitis, 315; in intestinal 
perforation, 697; in intussusception, 
322; in tuberculous peritonitis, 392, 394. 

Laryngeal spasm in bronchial asthma, 455; 
in rachitis, 346; in status lymphaticus, 
753. 
recurring, 600. 

Laryngeal stenosis, congenital, 56. 
in diphtheria, 551, 572, 579; in retropharyn- 
geal abscess, 443. 
intubation, in chronic, 592. 
specific, following intubation and decubitus, 
609. 

Laryngismus stridulus, following broncho- 
pneumonia, 798; typhoid, 798; whooping- 
cough, 798. 
with athrepsia, 798; rachitis, 798; tetany, 
798. 



964 



IXDEX. 



Laryngitis, complicating measles, 636. 
spasmodic, 444; diagnosis from diphtheritic 
croup, 444; predisposing factors, 443; 
prognosis, 446; treatment, 446; emetics, 
447; hypodermic medication, 448; inha- 
lations of steam, 446, 448. 
Larynx, congenital stenosis of, 56. 
foreign bodies in, 447. 
granulomata of, 889. 
growths of (see Papillomata), 888. 
in diphtheria, 551, 581. 
intubation in, 593. 

tolerance of, for intubation tube, 593. 
tracheotomy in stenosis of, 615. 
Late speaking, 3. 

Lateral curvature of the spine, 897. 
Lavage (see Stomach-washing). 
Lecithin, 210. 

Leeches, application of, to relieve cerebral 
congestion, 512. 
in convulsions, 783; in orchitis, complicat- 
ing mumps, 758; in rheumatism. 744. 
Leffert's nasal syringe, 427. 
Lentigo, 876. 

Leptomeningitis (see Pachymeningitis), S33. 
Leucocytosis, 72S. 
in chorea, 729; in diphtheria. 548; in nerv- 
ous diseases, 729; in pneumonia, 508, 728; 
in rachitis, 728; in scarlet fever, 647. 
polynuclear, increase in pus, 72S, 730. 
Leucomain poisoning, 750. 
Leucopaenia in typhoid, 696. 
Leukaemia, 735. 
blood in, 735, 736; diagnosis, 735; etiology, 
735; pathology, 735; spleen, 735; symp- 
toms, 735; treatment, 736. 
lymphatic form, 735. 
myelogenous form, 735. 
splenic form, 735. 
Lichen tropicus, 875. 
Liebermann phenol test for formaldehyde in 

milk, 913. 
Lien mobilis, 3S6. 
Lienteric stool, 229. 
Lime, saccharatcd solution of, 130. 
salts, in cows' milk, 127. 
water, in modification of cows' milk, 129. 
Lingual tonsil, in status lymphaticus, 753. 
Lipoma, 887. 

Lips, cyanosis of, in broncho-pneumonia, 458. 
in adenoid vegetations, 438: in cretinism, 
760; in septic diphtheria, 553. 
Lithaemia, 750; diet in, 751; etiology, 750; 
symptoms, 750; treatment, 751. 
urine in, 751. 
Lithiasis, appendicular, 313. 
Lithuria (see Lithaemia), 750. 
Liver, amyloid degeneration of (waxy), 383. 
cirrhosis of, 384. 
descended, 383. 
diseases of, 381. 
displacement of, 382, 3S3. 

in constipation, 2S5. 
fatty, 383. 
focal necrosis of, 384. 



functional disorders of, 3S2. 

in congenital obliteration of bile-ducts. 35; 
in diphtheria, 55: in faulty metabolism, 
332: in gastro-duodenitis, 252; in leu- 
kaemia, 735, 736; in malarial fever, 711; 
in pseudo-leukaemic anaemia, 737; in 
scarlet fever, 660; in tuberculosis, acute, 
530. 

spots (see Chloasma), 873. 

weight of, 381. 
Lobar pneumonia, 497. 
Lobular pneumonia, 456. 

Local anaesthesia, 931; by injection of sterile 
water, 932. 

blood letting, 938. 

remedies, 937. 
Lock-jaw (see Tetanus), 800. 
Loeffler's bacillus, 543. 
Lordotic albuminuria, 416. 
Loss of speech due to paralysis, 4. 

of vision due to pertussis, 489. 
Lumbago, 745. 

Lumbar puncture, 823, 829; amount of fluid 
to be withdrawn, 830; anaesthesia, 828; 
needle required, 829; place for puncture, 
829. 

dry-tap in, 830. 

in convulsions, 7S3; in hydrocephalus, 817; 
in meningitis, tubercular, S22; epidemic 
cerebro-spinal, 829; infantile spinal, 814. 
Lung, at term, 1. 

inflation of, 44. 

auscultation of, 450. 

cavities of, in chronic pulmonary tuber- 
culosis, 536. 

compressed, in pleurisy with effusion, 466. 

cut surface of, in acute pulmonary tuber- 
culosis, 536. 

gangrenous infiltration of, 228. 

in broncho-pneumonia, 459; in diphtheria, 
553; in empyema, 467, 470; in lobar 
pneumonia, 497, 498; in scarlet fever, 
660; in tuberculosis, acute, 451; in wan- 
dering pneumonia, 499. 

percussion of, 451; points in examination 
of, 450. 

position of, 450. 

transverse section of, in tuberculous bron- 
cho-pneumonia, 537. 
Lymph adenitis, retro-pharyngeal, 442. 
Lymphatic glands (Lymph Nodes), diseases 
of, 753. 

enlarged, causing torticollis, 747. 

in anaesthesia, 931; in mumps, 758. 

in diphtheria, acute, 548; local, 551; in 
leukaemia, 735; in pseudo-leukaemic 
anaemia, 737; in retro-cesophageal ab- 
scess, 234; in retro-pharyngeal abscess, 
442; in tonsillitis, 432; in tuberculosis, 
acute, 530. 
Lymphocytes, increase of, after second year, 
727. 

in diphtheria, 729; in malaria, 729; in pneu- 
monia, 729; in scarlet fever, 729; in ty- 
phoid, 729. 



[NDEX. 



965 



MacEwen's percussion note, 775. 
Macrocephalus, in epilepsy, 802. 
Macrocytes, in syphilis, 728. 
Mackenzie tonsillotome, 436. 
Magendie foramen, in hydrocephalus, 778. 
Malarial fever, 706. 

diagnosis, 714; differential, 714. 
pathology, 711; blood in, 711; liver in, 

711; spleen in, 711. 
Plasmodia in, 707. 
prognosis, 715. 
symptoms, 714. 

treatment, 715; quinine in, 715. 
aestivo-autuinnal, 709. 
double tertian, 706. 
quartan, 708. 
quotidian, 706. 
tertian, 706. 
Malformations of the rectum, 59. 

of the spinal cord, 807. 

Malignant endocarditis, 374. 

growth in bladder, 421. 

purpuric fever (see Meningitis, Epidemic), 
824. 
Malnutrition (see Athrepsia Infantum), 356. 

in chronic gastritis, 253; in rachitis, 348. 
Malt extract, in summer complaint, 155. 

soup, 167, 170, 907; in athrepsia, 360. 
Malted milk, Horlick's, 196. 
Maltose, 238. 
Mammary glands, 66. 
Management of woman's nipples, 9S. 
Mannaberg's table of malarial parasites, 713. 
Marasmic thrombosis, 860. 
Marasmus (see Athrepsia Infantum), 356. 
Marchand's test for fat in milk, 118. 
Massage, method of performing, 290. 
of breasts during lactation, 95. 
in cerebral paralysis, 839; in constipation, 

290; in spinal paralysis, 813. 
vibratory, 290. 
Mastitis neonatorum, 50. 

Mastoid disease, in otitis media, 857; oper- 
ation, 857; facial paralysis following, 
859. 
complicating influenza, 482. 
Masturbation, 796; causes, 796; prognosis, 797; 

symptoms, 796; treatment, 797. 
Materna home milk modifier, 150. 
Matzoon (see Zoolak), 209. 
Measles, 628. 

bacteriology, 628. 

complications, 635; broncho-pneumonia, 
636; croup, 640; diarrhoea, 640; diph- 
theria, 640; empyema, 639; eyes, 639; 
otitis, 638. 
diagnosis, 640; from drug eruption, 640; 

from influenza, 640; variola, 6"83. 
etiology, 628. 
immunity, 639. 
incubation period, 625. 
mortality, 628. 
pathology, 628. 
prognosis, 640. 
sequelae, tuberculosis, 519. 



symptoms, 630; desquamation, 633; erup- 
tion, 630, 632; enanthem, 630. 
treatment, 640; convalescence, 633; isola- 
tion, 040. 
German, 622. 

haemorrhagic form, 634. 
malignant form, 633. 
mild form, 633. 
relapsing form, 633. 
Meat juice, 211. 
Meckel's diverticulum, 35. 
Meconium, 263. 

Medication, points concerning, 936. 
hypodermic, 943, 944. 
local, 937. 
rectal, 939. 
Meig's food, 209. 
Melsena, 38. 
Mellin's food, 201; analysis, 202; formula for 

preparing, 202. 
Membrane, in diphtheria, 551, 558. 
Membranous conjunctivitis, 863. 
Meningitis, cerebro-spinal, 824. 
bacteriology, 824. 
diagnosis, 827. 

Brudzinski's neck sign, 826. 
etiology, 824. 
lumbar puncture in, 829. 
mortality in, 825. 
pathology, 824. 
prognosis, 831. 
serum, 831; symptoms, 825; eruption, 

826; Kernig's sign, 826. 
treatment, 831; intracranial injections, 
832; intraspinal injections, 832. 
tubercular, 819. 

bacteriology, 819. 

course, 821. 

diagnosis, 822. 

etiology, 819. 

lumbar puncture in, 823. 

pathology, 819. 

symptoms, 822; Babinski reflex, 823; 

Tache cerebrale, 823. 
treatment, 823. 
Meningococcus, 824; stain for, 929. 
Menstruation, effect of, on woman's milk, 64, 
66, 82. 
in chlorosis, 738. 
preecox, 404. 
vicarious, 404. 
Mental faculties, 2. 
Mercury, administration of, to children, 228, 

940. 
- in treatment of syphilis, 725. 
Metabolism, 242. 

fat, 116. 
Meteorismus (see Intestinal Colic), 293. 
Microcephalus, craniectomy in, 839. 
fontanel in, 770. 

in chronic hydrocephalus, 815; in epilepsy, 
802. 
Micrococcus catarrhalis, 824, 827. 
Microcytes, in syphilis, 728. 
Micro-organisms (see Bacteria). 



966 



IXDEX. 



Middle-ear abscess, causing abscess of brain. 

843. 
Migraine, 785. 

Miliaria papulosa, 875; rubra, 876. 
Miliary tuberculosis (see Acute Tubercu- 
losis), 516. 
Milk, Bulgarian, 183. 
casein, 124. 
cows', 99. 

a possible factor in the causation of 
scarlet fever, 643. 

addition of alkalies to, 129. 

adulteration of, 912; formaldehyde in, 
912; tests for, 912. 

albuminoids in, 121. 

analyses of, 99, 100. 

certified, in New York City, 103. 

chemistry of, albuminoids, 121; enzymes, 
127; fat, 116; milk-sugar or lactose, 
119; proteids, 122; salts, 126; starch, 
127. 

composition of, 99. 

condensed, 191. 

diluents of, 134. 

fresh, raw, 115. 

home modification of, 139. 

idiosyncrasies, 168. 

laboratory modification of, 173. 

pasteurization of, 164, 909. 

pasteurizer or sterilizer, 167. 

predigested or peptonized, 910. 

raw, 111, 113. 

sterilization of, 159; changes caused by, 
159, 160. 

sterilizers, 164, 167. 

top, 137. 

tuberculous infection through, 105, 115, 
116. 

undiluted, as a food for infants, 115. 

variation of.. 99. 
woman's (see Breast Milk), 64. 

analyses of, 65, 120; comparative, 67, 70, 
71. 

apparatus for examining, 66, 68. 

colostrum of, 64. 

composition of, 65; compared with dif- 
ferent infant foods, 196. 

conditions affecting composition of, 66; 
alcoholic drinks, 79; anaemia, 75; 
diet, 77, 97; drugs, 73; menstrua- 
tion, 75. 

nervous irritability, 73. 

deterioration in, 87. 

examination of, microscopical, 68. 

enzymes, diastatic, in, 69. 

fat, to decrease, 87; to increase, 87. 

how to increase quantity of, 73, 79. 

immunity conferred by, 69, 516, 566. 

method of changing ingredients in, 87. 

to preserve, 70. 

proteids, 87; to decrease, 87; to increase, 
87. 

reaction of, 69. 

scanty, 72. 

specific gravity, 66. 



specimen for examination, 67; how to 

procure, 67. 
variations in, 84. 
Milk of magnesia, 141, 296. 
Milk substitutes, Backhaus', 190; cereal, 197; 
Gaertner mother, 188; humanized, 203, 
909; Lahmann's vegetable, 187. 
Milk-sugar or lactose, 119. 
Milk-test, Babcock's, 117. 
Mitchell's milk modifying gauge, 152. 
Mixed feeding, 72, 90; additional foods during 

nursing period, 76. 
Mobius'sche kernschwund (see neuroplegia), 

839. 
Modified milk from milk laboratories, 173; 

prescription formulae, 173. 
Modified small-pox (see Varioloid), 685. 
Monarthritis, 402. 

in gonorrhceal vaginitis, 402. 
Mongolian idiocy, 846. 
Monoplegia, haemorrhage into sub-arachnoid 

space, causing, 778. 
Morbilli (see Measles), 628. 
Morbus coxarius, 898. 
Morbus maculosus Werlhofii, 748. 
Mortality, in cerebro-spinal meningitis, 824. 
in consumption, 525, 526. 
in diarrhceal diseases, 301, 302. 
in diphtheria, 541; and croup, 540. 
in diphtheria treated with and without 

antitoxin, 578. 
in infectious diseases, 475, 478. 
in intubated cases of diphtheria, 579, 580% 

581, 583. 
in measles and complications, 629, 634. 
in pulmonary tuberculosis, 524. 
in small-pox, 680. 

in tubercular diseases, 527, 528, 529. 
in whooping-cough, 486. 
of babies raised in incubators, 26. 
Morton's fluid, 818. 
Mosite in diabetes insipidus, 416. 
Mosquera's beef, meal, 206; analysis of, 206; 

jelly, 207. 
Motor function of the stomach, 916. 
Mouth-breathing, a symptom of adenoids, 

438, 439; of enlarged tonsils, 435. 
Mouth, condylomata of, in syphilis, 720. 
diseases of, 222. 

haemorrhage from, in syphilis, 719. 
hygiene of, 16. 

in adenoid vegetations, 438; in angina 
Ludovici, 233: in Bednar's aphthae, 225; 
in stomatitis aphthosa, 224; in stomati- 
tis catarrhalis, 223; in stomatitis 
mycosa, 225. 
Movable spleen, 386. 

Mucous membrane, conjunctival, in gastro- 
duodenitis, 252. 
of mouth, at birth, 236; in measles, 630. 
of pharynx, in scarlet fever, 652. 
of stomach, 236; in gastric catarrh, 243. 
of trachea and bronchi, in broncho-pneu- 
monia, 457. 



1XDEX. 



967 



Mucous disease, -97. 

in stools, 267. 
Muguet (see Stomatitis Mycosa), 225. 
Multiple neuritis, 793; causes, 794; course, 
793: symptoms and diagnosis, 794; treat- 
ment, 795. 
Mumps, 757. 

complications, 758; orchitis, 758. 

diagnosis, 757; differential, 758; from diph- 
theria, 758. 

etiology, 757; isolation, 759. 

period of incubation, 757; prognosis, 758. 

symptoms, 757. 

treatment, 758. 
Murmurs, 366. 

anaemic, 367. 

cardiac, 364, 366. 

cerebral blowing, 369. 

diastolic, 367. 

pericardial, 368. 

systolic, 366; in chlorosis, 738. 

venous, 368; in chlorosis, 738. 

vesicular, in bronchial asthma, 455. 
Muscles, atrophy of, in acute myelitis, 806; 
in poliomyelitis, 810, 812. 

fatty infiltration of, in pseudo-hypertrophic 
paralysis, 840. 

flabby, in faulty metabolism, 333; in rachitis, 
348. 

wasting of, in scurvy, 340. 
Muscular atrophy, in acute myelitis, 806; in 
poliomyelitis, 810, 814. 

in pseudo-hypertrophic paralysis, 840. 
Muscular, pseudo-hypertrophy, 840. 

rheumatism, 745. 

spasms, in rachitis, 346. 
Mustard foot bath, 641; in convulsions, 783. 

plasters, 938. 
Myalgia, 745. 

Myelitis, acute, 805; diagnosis, 806; etiology. 
805; pathology, 805; prognosis, 807; 
symptoms, 806; treatment, 807. 

chronic, 807. 
Myelocytes, 728. 

in diphtheria, 728; in leukaemia, 736; in 
pneumonia, 728; in syphilis, 728. 
Myocarditis, 379. 

causes. 379. 

complicating diphtheria, 559. 

diagnosis, 379. 

pathology, 379. 

prognosis, 380. 

symptoms, 379. 

treatment, 380. 
Myxcedema (see Cretinism), 760. 
Myxoedematous idiocy (see Cretinism), 760. 

Naevus, 878. 

Nails, in secondary anaemia, 734; in syphilis, 

719. 
Nasal catarrh, 425: etiology, 425: symptoms, 

425; treatment, 426. 

a symptom of measles, 426: of syphilis, 
719. 

causing otitis, 426. 



discharge, in diphtheria, 551, 553. 
douching, 428, 671. 
syringe, 427. 
Naso-pharyngeal catarrh, 428; in syphilis, 719. 
Navel, dangers in careless handling of, 33. 

management of, 16. 
Necrosis of liver, in malarial fever, 710. 
of jaw-bone, following stomatitis gan- 
grenosa, 228. 
Neck, in cretinism, 760. 
rigidity of, in typhoid, 694. 
stiff, in torticollis, 746. 
Neonatorum (see also New-born Infant), 
haemoglobinuria, 50. 
icterus, 48; urine in, 918. 
mastitis, 50. 
ophthalmia, 863. 
pemphigus, 52. 
sclerema, 49. 
Nephritis, acute, 405. 

as a complication, 407. 
blood in, 406. 

complicating influenza, 482. 
etiology, 405. 
pathology, 406. 
prognosis, 407. 
symptoms, 407. 
treatment, 408. 
urine in, 406, 407, 919. 
acute glomerulo-, 405. 
catarrhal, in scarlet fever, 656. 
chronic interstitial, from increased urinary 

pressure, 412. 
diffuse, in diphtheria, 552, 560. 
post-scarlatinal, 657. 
secondary, 408. 
Nerve, pneumogastric, in dyspeptic asthma, 

260. 
Nerves, in multiple neuritis, 793. 

vasomotor, causing asthmatic attacks, 455. 
Nervous impressions, effect of, on woman's 

milk, 73. 
Nervous system, diseases of, 775. 

in typhoid, 694. 
Nestle's food, 195; analysis of, 196. 

in acute milk infection, 156. 
Nettle rash (see Urticaria), 871. 
Neuralgia, interstitial, 293. 
complicating variola, 685. 
Neuritis, multiple. 793. 
causes, 794. 

complicating influenza, 482. 
course and prognosis, 795. 
symptoms and diagnosis, 794. 
treatment, 795. 
peripheral, 793. 
New-born, abnormalities of, 53; acute fatty 
degeneration of, 50; asphyxia of, 42; 
bleeding in, 720; Buhl's disease, 50; 
diphtheria in, 33; erysipelas in, 51; frac- 
ture in, 40; haemoglobinuria (Winckel's 
disease), 50; haemorrhage, gastro-intes • 
tinal, 38; into adrenal glands, 774: um- 
bilical, 33, 38; ichthyosis, 46; icterus, 49; 
inflation of lungs in, 44; malformations 



968 



INDEX. 



New-born (concluded). 

of, 53; mastitis, 50; paralysis of, 40, 842; 
pemphigus in, 52; peritonitis in, 52; scle- 
rema, 49; syphilis in, 716; tuberculosis 
in, 52, 517; typhoid in, 691. 
Night cough, 448. 

Night-sweats, in tuberculosis, 535. 
Night-terrors (see Pavor Nocturnus), 795. 
Nipple, anticolic, 158; sterilizer, 159. 
Nipple-shield, 94. 
Nipples for bottle feeding, 158. 
harelip, 54. 

management of woman's, 93; sore, 93; ten- 
der, 94; to harden, 94. 
Nitrous oxide and ether, 930. 
Nodding-spasm (see Spasmus Nutans), 785. 
Nodes, lymph (see Lymph Nodes). 
Nodules, subcutaneous tendinous, in rheuma- 
tism, 742. 
tubercular, 819, 820. 
Noma (see Stomatitis Gangrenosa), 227. 
Nose, discharge from, in diphtheria, 551, 553. 
diseases of, 425. 
foreign bodies in, 430. 
haemorrhage from, in exophthalmic goiter, 

772; in syphilis, 719. 
in adenoid vegetations, 438. 
in cretinism, 760. 
picking of, 325. 
Nose-bleed (see also Epistaxis), in diphtheria, 

559; in syphilis, 719. 
Nurse (see also Wet-Nurse), 21. 
Nursery, furniture in, 21; light of, 21; loca- 
tion of, 20; method of heating, 21; ven- 
tilation of, 20. 
Nursing (see also Feeding), 71. 
length of time for, 72. 
prolonged, causing rachitis, 344. 
schedule for, from birth to one year, 71. 
Nursing-bottles, 157; care of, 157. 
Nutrient enemata (see Rectal Feeding). 
Nutrients and stimulants, 209. 
Nutrition, improper, 332. 
Nutritive tonics, chemical analysis of, 208. 
Nutritive value of eggs, 210. 

value of eggs, 210. 
Nystagmus, complicating spasmus nutans, 785. 
in hereditary ataxy, 809. 

Oatmeal bath, 18; in eczema, 870. 
water, 906. 

Obliteration of the bile-ducts, congenital, 35. 

Obstetrical paralysis, 40. 

Obstipation, 333. 

O'Dwyer's method of intubation, 586. 

CEdema, in angina Ludovici, 233; in erysipe- 
las, 704; in variola, 685. 
of ankle, 738; of cheek, in stomatitis gan- 
grenosa, 228; of eyelids, in thrombosis 
of cerebral sinuses, 860; of feet, in mye- 
litis, 806; of glottis, in scarlet fever, 671; 
of larynx, 659; of lips, in myelitis, 806; 
of pia mater, 659; of scalp, 860. 

CEsophagitis, acute, 234. 
chronic or diphtheritic, 234. 



CEsophagus, foreign bodies in, 235. 

CEgophony, 465, 467. 

Oil, enema, in acute peritonitis, 389. 

internally in chronic constipation, 287. 
Oiled-silk jacket (see Pneumonia Jacket), 

514; how to make, 462. 
Omphalitis, diphtheritic, 33. 

septic, 34. 
Omphalomesenteric duct, 34. 
Onanism (see Masturbation), 796. 
Ophthalmia, granular, 864. 

neonatorum, 863. 

pneumococcus, 862. 

purulent, 863. 
Ophthalmo-tuberculin reaction, 533. 
Opisthotonos, hysterical, 791. 

in meningitis, 826. 
Orange juice in scurvy, 340. 
Orchitis, 400. 

in mumps, 758. 
Orthostatic albuminuria, 416. 
Osteitis, infectious, 903. 

of the femur, 901; of the tibia, 901. 
Osteoclasis in rachitis. :'..".",. 
Osteomyelitis (see Arthritis, Acute), 903. 
Osteotomy in rachitis, 355. 
Otitis, complicating diphtheria, 577; influenza, 
482; measles, 638; rhinitis, 426; scarlet 
fever, 653, 667; typhoid, 698; variola, 685. 
Otitis media, acute catarrhal, 854. 

bacteriology, 854. 

diagnosis, 856. 

etiology, 854. 

pathology, 855. 

prognosis, 856. 

symptoms, 855. 

treatment, 856; general, 856; operative, 857; 
prophylactic, 856. 
Oxygen, in dyspnoea and cyanosis, 513. 
Oxyuris vermicularis, 326. 
Ozaena, a sequela to scarlet fever, 661. 



Pachymeningitis, acute, 833. 
chronic, 833; diagnosis, 833; differential, 834; 
pathology, 833; prognosis, 834; symp- 
toms, 833; treatment, 834. 
haemorrhagic, 833. 
non-ha?morrhagic, 833. 
Pack, cold, 485; hot, 666. 
Palate, cleft. 54. 

feeding in, 54; gavage in, 54. 
in Bednar's aphthae, 225; in measles, 630; 
in purpura haemorrhagica, 748; in ru- 
bella, 623. 
paralysis of, in diphtheria, 562. 
Pallor of the skin, 180. 

Palpation of the liver, 381; of the spleen, 386. 
Palsy (see Paralysis). 

acute spinal, from acute cerebral, 810. 
Paludal fever (see Malarial Fever), 706. 
Pancreas, diseases of, 387. 
function of, 387. 
in syphilis, 719. 
position of, 387. 



INDEX. 



969 



Pancreatic juice, 236. 

Panopepton, 207; analysis of, 207. 

Panophthalmitis, in meningitis, 826. 

Papillomata, 888. 

Paracentesis, in otitis, 068. 

Paralysis, following pertussis, 489, 834. 

in hereditary ataxy, 809; in multiple 
neuritis, 794; in Pott's disease, 893; 
in thrombosis of cerebral sinuses, 
860. 
of vocal cords, following intubation, 607, 
611. 
Bell's, 842. 
cerebral, 834. 

acquired after labor, 835. 
course, 838. 

diagnosis, 836; differential, 838; from in- 
fantile spinal paralysis, 838. 
etiology, 834. 

occurring during labor, 835. 
of intra-uterlne onset, 835. 
pathology, 834. 
symptoms, 836. 

treatment, 839; operative, 839. 
facial, 842. 

following mastoid operation, 859; retro- 
pharyngeal abscess, 842. 
in new-born, 842. 
infantile spinal, 809. 

diagnosis, 812; from cerebral paralysis, 

838. 
etiology, 809. 
pathology, 809. 
prognosis, 812. 
symptoms, 810. 

treatment, 812; muscle education, 812. 
post-diphtheritic, 561, 577. 
frequency of, 562. 

of bladder, 562; of extremities, 563; of 
palate, 562; of rectum, 562; of trunk, 
562. 
Paraphimosis, 398. 

Paraplegia (see Paralysis, Cerebral), 834. 
Parasitic stomatitis (see Stomatitis Mycosa), 

225. 
Parotitis, specific (see Mumps), 757. 
Pasteurization of cows' milk, 164, 909. 
Patellar reflexes, 552; in cerebral paralysis, 
836; in meningitis, 826; in pseudohyper- 
trophic paralysis, 842. 
Patent foods, 193. 
Pavor nocturnus, 795. 
Pediculosis, 875. 
Peliosis rheumatica, 748. 
Pelvis, in congenital dislocation of hips, 900; 

in rachitis, 348. 
Pemphigus, chronic, 878. 
in syphilis, 719. 
neonatorum, 52. 
Pendulous belly, in rachitis, 350. 
Pepsin, 236. 
function of, 237, 238. 
in gastric contents, 916. 
Peptogenic milk powder, 203; analysis of, 203. 
Peptone, in gastric contents, 916. 



Peptonized milk, 910. 
Percussion of the lung, 451. 
of the skull, 775. 
resonance, 451. 
Pericardial murmurs, 368. 
Pericarditis, 375. 

bacteriology, 375. 

complicating diphtheria, 559; rheuma- 
tism, 743; typhoid, 698. 
etiology, 375. 
pathology, 376. 
physical signs, 376. 
prognosis, 377. 

symptoms and diagnosis, 376. 
treatment, 377; aspiration of pericar- 
dium, 377. 
chronic, with adhesions, 377; diagnosis, 377; 
symptoms, 377; treatment, 378. 
Pericardium, aspiration of, 377. 

tuberculosis of, 378. 
Perinephritis, 409; bacteriology, 409; etiology, 
409; pathology, 409; prognosis and 
course, 410; symptoms, 410; treatment, 
410. 
blood in, 410. 

diagnosis from hip-joint disease, 410. 
simulating Pott's disease, 41o; sciatica, 410. 
Perineum, in imperforate anus, 5D. 
Periosteum, in rachitis, 342, 343. 
Periostitis, complicating stomatitis gangre- 
nosa, 228. 
Peripheral neuritis (see Multiple Neuritis;, 

793. 
Peritoneum, diseases of, 388. 
Peritonitis, acute, 388. 
ascites due to, 393. 

bacteriology, 388; etiology, 388; pathology, 
388; prognosis, 389; symptoms, 388; 
treatment, 389; operative, 389. 
complicating rheumatism, 742; typhoid, 698. 
chronic, 389. 

diagnosis, 390; symptoms, 390; prognosis, 
392; treatment, 392; laparotomy, 392; 
light, 392; serum, 392. 
fibrinous, 388. 
fibrous form, 390. 
in the new-born, 52. 
non-tuberculous, 389. 
purulent, 388. 
serous, 388. 
tuberculous, 390. 
Peritonsillar abscess, 433. 

resembling diphtheria, 558. 
Perityphlitis (see Appendicitis), 315. 

tuberculous, 519. 
Pernicious anaemia, 734. 
Perspiration (see also Sweating), 12. 
Pertussis, 486. 
bacteriology, 487. 

complications, 488; aphasia, 489; broncho- 
pneumonia, 488; cerebral haemorrhage, 
489; convulsions, 489; diabetes mellitus, 
489; emphysema, 489; empyema, 489; 
epistaxis, 489; hernia, 489; loss of vis'on, 
489; nephritis, 489; paralysis, 489, 834; 



970 



INDEX. 



Pertussis (concluded). 

pleurisy, 489; prolapse of rectum, 489; 
scarlet fever, 652; strabismus, 489. 
course, 489. 
diagnosis, 488. 
etiology, 486. 
pathology, 487. 
prognosis, 489. 

sequelae, tetany, 798; tuberculosis, 519. 
stages, catarrhal, 487; of decline, 488; par- 
oxysmal, or whooping, 488. 
symptoms, 487. 
treatment, 489. 
Petechia, in haemophilia, 752; in purpura, 747. 
Peyer's patches, 261. 

in athrepsia, 357; in typhoid, 690. 
Pharyngeal catarrh, causing spasmodic croup, 

444. 
Pharyngitis, 442; granular, Plate XIV; in 

influenza, 481. 
Pharynx, in local diphtheria, 551; in scarlet 
fever, 647; in septic diphtheria, 553; in 
stomatitis aphthosa, 224; mycosa, 225. 
Phimosis, 397; symptoms, 398; treatment, 398; I 
operative, 398. 
causing chorea, 398; night-terrors and in- 
somnia, 398. 
Phlegmonous tonsillitis, 433; symptoms, 433; 

treatment, 434. 
Phloroglucin test for formaldehyde in milk, 

912. 
Phlyctenular conjunctivitis, 868. 
Phosphorus, in rachitis, 353. 
Photophobia, • in cerebro-spinal meningitis, 

826; in influenza, 482; in measles, 630. 
Phthisis (see Pulmonary Tuberculosis), 535. 

pulmonis, mortality in, 524. 
Physical examination of heart, 363. 
of lungs, 450; auscultation, 450; breathing, 
451; percussion resonance, 451; rhythm, 
451; vccal resonance, 451. 
Physical signs, in empyema, 467; in lobar 
pneumonia, 506, 507, 509; in pleurisy 
with effusion, 465. 
Pia mater, blood-vessels of, 778. 
closure of, in hydrocephalus, 778. 
in tubercular meningitis, 819. 
Pigeon-breast (see Prominent Sternum), 57. 

in rachitis, 342, 346. 
Pigmentary naevus, 878. 
Pinworms, 329. 
Pink eye, 862. 
Plasmodium malarise, 706. 
Plasmon, 206. 
Pleura, diseases of, 450. 
effusion into, 465. 
inflammation of, in pleuro-pneumonia, 501; 

in scarlet fever, 660. 
swollen, in dry pleurisy, 463. 
Pleurisy, 463. 

complicating diphtheria, 559; pertussis, 

489; rheumatism, 742. 
diagnosis, 464. 
pathology, 463. 
prognosis, 464. 



symptoms, 463; cough, 463. 
treatment, 464. 
dry, 463. 
purulent, 466. 
with effusion, 464. 
bacteriology, 464. 

diagnosis, 465; exploratory puncture, 465. 
pathology, 464. 
symptoms, 465; cough, 465; physical 

signs, 465. 
treatment, 466; diet, 466. 
Pleuritis, exudativa, 464. 
Pleurodynia, 745. 
Pleuroplegia, 839. 
Pleuropneumonia, 501. 
Pleurothotonos, in pericarditis, 376. 
Pneumococcus, in broncho-pneumonia, 457; 
in empyema, 467; in follicular tonsillitis, 
432; in measles, 638; in meningitis, 824; 
in perinephritis, 409; in pleurisy with 
effusion, 464; in pleuro-pneumonia, 501. 
ophthalmia, 862. 
Pneumo-gastric disturbance, causing asth- 
matic attacks, 260, 455. 
Pneumonia (see Broncho-pneumonia), 
abortive, 499. 
catarrhal, 456. 
cerebral, 502. 
gastric, 499. 
lobar, 497. 

bacteriology, 497. 
course, 506. 

etiology, 497; age, 497; lobe affected, 497. 
pathology, 499. 

symptoms, 506; blood, 506; pulse, 507; 
ratio of pulse and respirations, 506; 
relapse, 509; respirations, 507; tem- 
perature, 507; crisis, 507, 508; pro- 
crisis, 508; urine, 508. 
treatment, 510; antipyretics, 511; feed- 
ing, 514; isolation, 510; oxygen, 513; 
stimulants, 513. 
lobular, 497. 
migrans, 499. 
pleuro-, 501. 

bacteriology, 501. 
pathology, 501. 
prognosis, 502. 
symptoms, 501. 
treatment, 502. 
tuberculous, 514. 

cavities, 514; course, 515. 
chronic type, 515. 
rapid type, 515. 
wandering, 499. 
Pneumonia jacket, 461. 
Pock, in varicella, 676. 
Poikilocytosis, in syphilis, 728. 
Poisons (see also Toxins), 
causing toxic multiple neuritis, 794. 
elimination of, 274. 
Poliomyelitis (see Paralysis, Infantile Spinal), 
809. 
acute anterior, from post-diphtheritic pa- 
ralysis, 563. 



IXDEX. 



971 



Polyarthritis (see Rheumatism), 740. 
Polydipsia (see Thirst, Excessive). 
Polymorphonuclear cells, in erysipelas, 728; 
in diphtheria, 728; in pneumonia, 728; 
in scarlet fever, 728. 
Polyneuritis (see Multiple Neuritis), 793. 
Polynuclear leucocytes, increase of, in pus, 
730. 
in infectious diseases, 728. 
Polypus, rectal, 331; umbilical, 34. 
Polyuria, 416; in diabetes mellitus, 419. 
Porencephaly, 818. 
Post-operative palsy (see Facial Paralysis), 

842. 
Pot-belly in rachitis (see also Pendulous 

Belly), 261. 
Pott's disease, 890. 
bacteriology, 891. 
complications, 893; abscess, 893; paralysis, 

893. 
differential diagnosis from rachitis, 355. 
etiology, 890. 

pathology, 891; anatomical landmarks, 891. 
prognosis, 895. 

symptoms, 892; of lower region, 892^' of mid- 
dle region, 893; of upper region, 893. 
treatment, 896. 
Poultices, flax-seed, in retro-pharyngeal ab- 
scess, 443; in tonsillitis, 431; how to 
make, 937. 
ginger, 938. 
Powders, dusting, 678; talcum, 17; velvet 

skin, 17. 
Precordia, prominence of, 364. 
Predigested milk, 910. 

Pregnancy, effect of, on nursing infant, 30. 
Premature infants, 24. 
method of feeding, 28; artificial feeding, 30. 
mortality of, 25. 
prognosis, 31. 
serum injections, 31. 
weight, 31. 
Prepuce, adherent, 397. 

tight, causing enuresis, 423. 
Prescriptions for various diseased, 911. 
Pre-tubercular anaemia, 530. 
Priapism, in phimosis, 397. 
Prickly heat, 875. 
Procrisis, in pneumonia, 508. 
Proctitis, croupous, 329. 
simple catarrhal, 328. 
ulcerative, 329. 
Prolapse of rectum, following pertussis, 489. 

in diseases of the bladder, 414, 420. 
Prolapsus ani, 330; causes, 330; diagnosis, 

330; treatment, 330. 
Prominent sternum, 57. 
Propeptone in gastric contents, 916. 
Prophylaxis in diphtheria, 564. 
Proprietary infant foods, 193. 
Proteid indigestion, causing colic and con- 
stipation, 96. 
Proteids, function of, in diet, 122. 
in cows' milk, 122. 

in excess, causing colic. 294. 



in woman's milk, 86. 

determination of, 124. 
to increase, 87. 

Woodward's burette for estimating, 125. 
Protrusion of ears, 56. 
Prune-water, 147. 
Pseudo-appendicitis, 316. 
Pseudo-diphtheria, 619. 

age and mortality in, 620. 

bacteriology, 619. 
Pseudo-hypertrophic paralysis, 840. 
Pseudo-leukaemic anaemia, 736. 

etiology, 736. 

pathology, 736; blood, 737; spleen, 737. 

prognosis, 737. 

treatment, 737. 
Pseudo-paralysis, in scurvy, 337; in syphilis, 

723. 
Pseudo-pertussis, 449. 
Psoriasis, 873. 

Ptosis in thrombosis of cerebral sinuses, 860. 
Ptyalin, function of, 238. 

Pulmonary artery, thrombosis of, in diph- 
theria, 559. 

gangrene, 462. 

gymnastics, 23. 

in empyema, 470; in tuberculosis, 535. 

stenosis, 369; prognosis, 370. 

tuberculosis, 535. 
Pulse, in diagnosis, 366. 

of high tension, 363; of low tension, 363. 
Pulse-rate asleep, 10; awake, 10. 

in bronchial asthma, 455; in bronchitis, 433; 
in broncho-pneumonia, 458; in diagnosis, 
10; in diphtheria, 552, 553; in lobar 
pneumonia, 506. 
Pulsus paradoxus, 366. 
Pump, breast, 95. 
Pupils, as diagnostic aid, 12. 

in cerebro-spinal meningitis, 826; in chorea, 
788; in insolation, 851; in myelitis, 806; 
in pachymeningitis, 833. 
Purpura, 747. 

complicating rheumatism, 742. 

diagnosis from scurvy, 748. 

haemorrhagica, 748. 

rheumatica, 748. 
Purulent ophthalmia, 863. 

pleurisy, 466. 

synovitis, acute, 903. 
Pus corpuscles in urine from a case of post- 
scarlatinal nephritis, 658. 
Pyaemia, complicating measles, 639; typhoid, 
698. 

in acute arthritis, 903. 
Pyelitis, 411. 

causes, 411. 

diet in, 413. 

in gonorrhceal infections, 402. 

pathology, 412. 

prognosis, 413. 

treatment, 413. 
Pyelo-nephritis (see Pyelitis), 411. 
Pyloric obstruction, 248. 

causes, 248. 



972 



INDEX. 



Pyloric obstruction (concluded). 

diagnostic aid, 248. 

symptoms, 248. 
Pylorus, spasm of, 248. 
Pyuria, 415; in colicystitis, 419; in 
412. 



pyelitis, 



Quartan intermittent fever, 708. 
Quincke's lumbar puncture, 827. 
Quinsy, 433. 

resembling diphtheritic tonsillitis, 554. 
Quotidian intermittent fever, 707. 

Race, influence of, upon tuberculosis, 525. 
Rachitis, 341. 
causes, 333, 344. 
course, 351. 
deformities of, 347. 
diagnosis, 351; differential, 351; from Pott's 

disease, 355. 
diet in, 352. 

laryngeal stenosis in, 603. 
prognosis, 351. 
prophylaxis, 351. 

symptoms, 346; blood in, 728; teeth, 345. 
tetany in, 798. 

treatment, 351; dietetic, 352; hygienic, 351; 
medicinal, 352; surgical, 355; of deformi- 
ties, 353; kyphosis, 354. 
Ranula, 232; character, 233; symptoms, 233; 

treatment, 233. 
Rashes (see Eruptions). 
Raw milk, 111, 113, 115. 
Raynaud's disease, 883. 
Reaction of degeneration, 779. 
in acute myelitis, 806; in acute poliomyelitis, 
811; in multiple neuritis, 794; in obstet- 
rical paralysis, 41. 
of human milk, 69. 
Rectal feeding, in acute milk infection, 311; 
in bronchitis, 454; in cerebro-spinal 
meningitis, 823; in dysentery, 284, 286. 
injections (see also Enemata and Irriga- 
tion), 
polypi, 331. 
Rectum, congenital, absence of, 60. 
diseases of, 328. 
imperforate, 59. 
malformations of, 59. 
narrowing of, 59. 

prolapse of, following pertussis, 489. 
protrusion of, 330. 
stimulation by, 513. 

terminating in bladder, 69; in vagina, 60. 
Red gum (see Miliaria Rubra), 876. 
Reflex cough, 449. 

Reflexes, in acute myelitis, 806; in cerebral 
paralysis, 836; in spinal paralysis, 811. 
patellar, in diphtheria, 552; in cerebro- 
spinal meningitis, 826; in hereditary 
ataxy, 809; in pachymeningitis, 834. 
Regurgitation of food in pyloric obstruction, 

248; nasal, 443, 562. 
Remittent fever (see Malarial Fever), 706. 
Rennet, action of milk on, 127. 



test for, in gastric contents, 916. 
Resection of ribs, 469. 
Resonance, percussion, 451. 

vocal, 451. 
Respirations (see also Breathing), 
artificial, 43. 
asleep, 11. 
awake, 11. 
Cheyne-Stokes, in tuberculous pneumonia, 

515. 
in bronchial asthma, 455; in bronchitis, 453; 
in broncho-pneumonia, 458; in infancy, 
11; in lobar pneumonia, 506, 507; in 
tubercular meningitis, 826. 
wheezing, 455. 
Respiratory system, diseases of, 425. 
Rest treatment in chorea, 789. 
Restlessness at night, a symptom of worms, 
325. 
in constipation, 287; in faulty metabolism, 
333; in gastroptosis, 256; in rachitis, 351. 
Resuscitation of the new-born, 42. 

Byrd's method, 43. 
Retraction of head, in cerebro-spinal menin- 
gitis, 826; in epilepsy, 803; in influenza, 
482. 
Retro-cesophageal abscess, 234. 
Retro-pharyngeal abscess, 443. 
diagnosis, 443. 
pathology, 443. 
symptoms, 443. 
treatment, 444. 
complicating cerebral pneumonia, 503. 
lymph adenitis, 442. 
Retro-pharynx a possible point of entrance 

of tubercle bacilli, 518. 
Rhagades of anus and mouth tn syphilis, 719, 

723. 
Rheumatic torticollis, 747. 
Rheumatism, acute, 740. 
bacteriology, 741. 
complications, 742. 
course, 742. 
etiology, 740. 
prognosis, 742. 
symptoms, 741; subcutaneous .endinous 

nodules, 742. 
treatment, 743; dietetic, 744; medicinal, 
744; prophylactic, 743. 
articular, 742. 
chorea in, 742. 
following tonsillitis, 741. 
muscular, 745. 
purpura in, 742. 
Rhinitis (see Nasal Catarrh), 425. 
Rhinolith, 429. 
Rhino-pharynx, method of examining for 

adenoids, 439. 
Rhythm, 451. 

Ribemont's tube for inflating the lungs, 44. 
Ribs, beaded, in rachitis, 342, 346. 

resection of, in empyema, 469. 
Rice water, 906. 
Rickets (see Rachitis), 341. 
Rimini test for formaldehyde in milk, 912. 



INDIA 



973 



Ringworm (see Tinea Tonsurans), 
Robert's trst tor albumin In urine, 923. 
Roentgen rays as diagnostic aid, 14, 15. 
Rotary spasm of bead (see spasmus Nutans), 

TV,. 

Rdtbeln (see Rubella), 622. 
Round worms, 325. 

Rubella. 622. 

bacteriology, 622. 

complications, 627. 

course, 027. 

desquamation. 626. 

diagnosis, 02:'.; differential, 625. 

eruption, 624. 

etiology, 622. 

pathology, 622. 

period of invasion, 623. 

prognosis, 627. 

symptoms, 623; subjective, 625. 

treatment, 627. 
Rubeola (see Measles), 628. 
Rules to be observed in taking temperature 

of infants, 12. 
Rupture (see also Hernia). 

of spleen, in malarial fever, 710. 



Sacral tumor, congenital, 58. 
Saint Vitus's dance (see Chorea), 786. 
Salicylic-sulphur paste, 871. 
Saline solution, for colonic flushings, 672; in 
erysipelas, 705. 
cold, in typhoid, 699. 
subcutaneous injections of, 666, 672. 
Saliva, action of, on bacteria, 237. 
in stomatitis gangrenosa, 227. 
secretion of, at birth, 236. 
Salt, free diet in scarlet fever and nephritis, 

667. 
Salts in milk, 126. 

Salvarsan, injections in syphilis, 723. 
Sarcoma, spindle-cell of the thorax, 884. 
Scabies, 883. 

Scalp, fatty growths of (see Lipoma), 887. 
in caput succedaneum, 58. 
ringworm of, 878. 
seborrhcea of, 876. 
Scarlatina (see Scarlet Fever), 
papulosa, 651. 
post-operative, 661. 
sine angina, 652. 
sine exanthemata, 651. 
sine febre, 651. 
variegata, 651. 
Scarlet fever, 643. 
bacteriology, 645. 

complications, 652; angina Ludovici, 655; 
coma, 665; diphtheria, 652, 672; endo- 
carditis, 667; heart, 658; kidneys, 6.~>n; 
lungs, 660; measles, 652; nephritis, 605; 
otitis, 653; pericarditis, 667; retro- 
pharyngeal abscess, 655; thrombosis of 
veins of Galen, 860; whooping-cough, 



diagnosis, 663; from variola, 



etiology, 643. 

Incubation, stage of, 645. 
Isolation, 664. 
pathology, 647. 

prognosis, tit;:;. 

rash, 648. 

symptoms, 647; tongue, 647; urine, 648. 

treatment, 664; diet, 667, 668; hygienic, 664; 

medicinal, 670; restorative, 667; scrum, 
668. 
varieties of, 649; septic, 650; toxic, 649. 
vulvo-vaginitis following, 402. 
Schonlein's disease, 748. 
Sciatica, 410. 

Sclerema neonatorum, 49. 
Scorbutus (see Scurvy), 335. 
Scrofula (see Tubercular Adenitis), 755. 
lesions of, 724. 
resembling tuberculosis, 517. 
Scurvy, 335. 
caused by prolonged sterilized milk feed- 
ing, 161. 
diagnosis, 337. 
etiology, 335. 
pathology, 336. 
symptoms, 337. 
treatment, 340. 
Seborrhcea, 876. 

Secondary anaemia, 734; causes, 734; diag- 
nosis, 734; prognosis, 734; symptoms, 
734; treatment, 734. 
Seller's solution, 428. 
Senses, development of, 2. 
Sensitive skin, 18. 
Septic diphtheria, 553. 
nephritis, complicating scarlet fever, 657. 
omphalitis, 34. 
Serum injection, intraventricular method of, 

828. 
Serum injections in premature infants, 31. 

in gastro-intestinal haemorrhage, 39. 
Serum test for typhoid, 692. 
treatment of diphtheria, 570; of dysentery, 
283; of erysipelas, 705; of meningitis, 
832; of scarlet fever, 668; of tetanus, 801; 
of typhoid, 698. 
Shiga bacillus, 280. 
Shingles (see Herpes Zoster), 873. 
Shock, in intussusception, 322; in operative 
appendicitis, 315; in typhoid fever, 699. 
Shoe, proper, 19. 

Shoulders in lateral curvature of spine, 897. 
Sigmoid flexure, 261, 262. 

abnormalities of, 284, 286. 
Simple catarrhal proctitis, 328. 
Singultus, in pericarditis, 376; in typhoid, 698. 
Sitting, when established, 2. 
Skin, cachectic, in syphilis, 721. 
diseases of, S6S; blood in, 728. 
in Addison's disease, 774; in chlorosis, 738; 
in cretinism, 760; in eczema, 869; in 
erythema infectiosum, 674; in faulty 
metabolism, 332; in foetal ichthyosis, 46; 
in gastro-duodenitis, 252; in meningitis, 
827; in Mongolian idiocy, 846; in 



J74 



ES'DEX. 



::;!- ::.:.:-: ".-- :n 

leoiaemie ansmia, 737; in 
i ^ V _ 

in _;-::: t::;_: . ; l r 

in :■; :_.:.; ~Al 

;^::_? ; ::- :. " r 
Sleep, as diagnostic aid, M. 

examination daring 

proper training .. 

palse-rate during, ML 

restless (see Restlessness at Night). 
Smail-r:- see ariola), 680. 

~i-:::l; in i_t:5;t; -V 1- :_:-";. :'_:; 
~. f:; --t loryza 

_ -Tpnilis 715 
Snoring, a symptom of nypertropnied tonsils, 

,:. r 

-.':■'■ i :--.: :-; _::—¥--- i-- 




STmptonxs 

- i r-i '. 7 =; = : : : -4 

. : - 71* 
-; .tt: : -t - ?-= :: •■- 

enlargement of, 286. 




in :i::r:;:s "i.v i: 

niiiria. "11: in "ilirnan: 

- ..-;..-.-. - • " - 
Ir-i-e—;: i-.^zi:2 "" in :•:::.= 
in soar '.-;■: z^^t ■:>_: in 



:: :- 
:: ~ 



in :::;:: 
-::i;t :a:n_; :: r-i- ^ z-zzzz -zzz -- 

; ;:::::r:.; ::-n::r::rr 

-;:::-: Zt~-: =ee llrning.:i= Z; U~ 



S::r - ;;.; ••"; ::r.:n_ri- ::' -i 



• 



zz .'az'.z: ! 1 

— n=.:nlir :n ra:n:-.:= V 
:: ;r-:n:niil m n;.;'.rs -" 
:: f.-.nis --'.' 

of larynn. IS ; in raehitis, 3£6u 
of pylorus. Ml 
S;i;ni: : : ::ign i-t; 
: : :; ±44 
:::;ir - r 444 



ria ■ 

- 



l-tl 



:: t :-:ra:i:n 



-:■. 

:■«: 



:•:■: :n 



treating- : --" soap-kettle Hi eme- 
tics is 



: i ::'.'.; :n -1 ; 



:n :r-:n:n:-.:= ^ T l in 
S7; in diphtheria, 




; - r ; - .-. ' L - ■ z. 



t'.z-.z~ i •-' -i :'nrin:: 
tubercular meitir g . : . 



- 



ig intubation 



[NDEX 



'.i7.') 



Stenosis (concluded). 

etiology. 609; pathology, 610; treat- 
ment, 612. 
in diphtheria, 561, .".72. ;>7'.'. 
in retro-pharyngeal abscess, 143. 
intubation in, 392. 
recurring, 600. 
pulmonary, 
spasmodic. 248. 
sub-glottic, in syphilis, 721. 
Stercoraceous vomiting (see Faecal Vomiting). 
Sterilization of milk, 159. 
causing constipation, 162. 
chemical changes produced by, 111. 
disadvantages of, 161. 
scurvy, caused by, 161, 337. 
Sterilizers, milk, 164. 
Sterno-mastoid, haematoma of, 57. 
Sternum, prominent, 57; depressed, 57. 
Stethoscopes, 364. 
Stimulant, coffee as a, 213. 

whisky as a, 214, 513. 
Stomach, acids in, 237. 
anatomy of, 236. 
capacity, 239. 
diseases of 236. 
haemorrhage from, in exophthalmic goiter, 

772. 
infantile, 236. 
low position of, 256. 
motor function of, 916. 
mucous membrane of, 236. 
physiology of, 236. 
translumination of, 255. 
ulcer of, 258. 

unorganized ferments in, 237. 
Stomach-washing, 307. 

in acute gastric catarrh, 244; in chronic 
gastrititis, 254; in summer diarrhoea, 
307. 
technique of, 308. 
Stomatitis, 222. 

complicating scarlet fever, 660. 
in athrepsia, 358; in syphilis, 725. 
aphthosa, 223; causes, 223; diagnosis, 224; 

symptoms, 224; treatment, 224. 
catarrhalis, 222; symptoms, 223; prognosis, 

223; treatment, 223. 
croupous or diphtheritic, 226. 
gangrenosa, 227. 

mycosa, 225; symptoms, 225; treatment, 226. 
syphilitic, 227. 
Stone in the bladder, 420. 

Stool, casein in, 263, 265; curds, white in, 265; 
diastatic enzymes in, 69; excess of fat 
in, 267; peptonizing ferment, 265; pro- 
teids in, 266; reaction of, 264; sugar in, 
266; quantity of, 264. 
bloody, 267, 559; in Henoch's purpura, 750; 
in intussusceptions, 323; in syphilis, 719. 
brown, 267. 

disinfection of, 935; in typhoid, 700. 
dyspeptic, 268. 
green, 248, 264. 



in athrepsia, 367; in derangement of liver, 
in dysentery, 281; in faulty metab- 
olism, 333; in gastro-duodenitis, 2.">2; in 
gastro-intestinal haemorrhage (melaena), 
uS; in scarlet fever, toxic, 660; in 
typhoid, 693. 
in pyloric stenosis, 248. 
lienteric, 296. 
mucus, 267. 
normal, 2<;::. 

of buttermilk-fed infant, 186; of nursling, 
263. 
Scybalous, 268. 
thin, watery, 149. 
white or light gray, 267. 
Strabismus, following cerebral paralysis, 836. 
cerebro-spinal meningitis, 826. 
pertussis, 4S9. 
in tubercular meningitis, 820. 
Streptococci, in acute peritonitis, 388; in 
bronchitis, 452; in broncho-pneumonia, 
457; in erysipelas, 702; in empyema, 467; 
in follicular tonsillitis, 432; in measles, 
625; in meningitis, 827; in perinephritis, 
409; in pleurisy with effusion, 464; in 
pseudo-diphtheria, 619. 
smear from throat exudate, 345. 
stain for. 929. 
Strepto-diplococcus in scarlet fever, 645. 
Streptolytic serum in treatment of scarlet 

fever, 669. 
Strophulus infantum (see Miliaria Rubra), 

876. 
Stupe, turpentine, 937. 

Stuttering, 786; a sequela to scarlet fever, 786 
Stye, 867. 

Subacute milk infection, 308. 
Subarachnoid space, fluid in, 778. 

haemorrhage into, 778. 
Subcutaneous haemorrhage in scurvy, 337. 
tendinous nodules, in rheumatism, 742. 
Submaxillary glands, in diphtheria, 551, 553; 

in scarlet fever, 647, 655. 
Subnormal temperature, in athrepsia infan- 
tum, 358; in bronchitis, 453; in myocar- 
ditis, 379. 
Subphrenic abscess, 385. 
Substitute foods, 182. 
Sucking, 236. 
Sucrose, 120. 
Sudamina, 876. 

Sudden death, caused by enlarged thymus, 
753, 773. 
careless injection of antitoxin, 570. 
in diphtheria, 559, 564. 
in myocarditis, 379. 
in pertussis, 489. 
Suffocation from vomited milk, 26. 

reflex, in angina Ludovici, 233. 
Sugar, 119; excess of, causing colic, 121, 293. 
nutrient value of, 121. 
cane, 120. 
in urine (see Glycosuria). 

test for, 925. 
milk, 119. 



976 



IXDEX. 



Sulphur baths, 831. 
Summer diarrhoea, 308. 

Sunlight, iu treatment of chlorosis, 739; of 
peritonitis, 392; of tuberculosis, 534; of 
typhoid, 700. 
Sunstroke (see Insolation), 851. 
Superficial gangrene, 881. 
Supplementary head, 58. 
Suppositories, 289. 

in constipation, 289; in dysentery, 283. 
Suprarenal capsules, 405. 

Sutures, separation of, in hydrocephalus, 815. 
Sweating, head, in rachitis, 246. 
in acute tuberculosis, 535; in malarial fever, 
714; in very young infants, 12. 
Symmetrical gangrene, 883. 
Symptoms and diagnosis (see Diagnostic Sug- 
gestions), 9. 
Syncope in pericarditis, 376. 
Synovitis, complicating scarlet fever, 656. 
followed by knee-joint disease, 905. 
purulent, 903. 
Syphilis, 716. 

congenital, 723, 724. 
diagnosis, 721. 

differential, 721; from faulty metab- 
olism, 334; from tuberculosis, 
721; from variola, 685. 
modes of infection, 716. 
pathological anatomy, 718. 
prognosis, 723. 

intubation in, 592. 
spirochete pallida, 718. 

refringens, 718. 
stomatitis in, 725. 

symptoms, bones, 718; haemorrhages, 
719; lesions, 721; skin lesions, 720; 
teeth, 720, 722. 
transmission of, 723. 
treatment, 723. 

Wassermann reaction in, 721. 
haemorrhagic, 719. 
hereditary (see Inherited), 
inherited, 716. 

Colles's law, 717. 
contagion of, 717. 
Syphilitic stomatitis, 227, 725. 

teeth, 720, 722. 
Syringe, nasal, 427. 
Systolic murmurs, 366. 

Tache cerebrale in tubercular meningitis, 826. 
Tachycardia, 366. 

in diphtheria, 552; in exophthalmic goiter, 
772. 
Taenia, cucumerina, 323. 

mediocanellata, 323. 

sodium, 323. 
Talipes, congenital, with rachitis, 355. 
Tannin-sulphur paste, 880. 
Tapeworms, 323. 

Tapping the abdomen in ascites, 394. 
Tea, 215. 
Teeth, eruption of, 7. 

grinding of, a symptom of worms, 325. 



hygiene of, 16. 

in adenoid vegetations, 438; in cretinism. 
760; in rachitis, 345; carious, 346; in 
stomatitis gangrenosa, 225; in syphilis, 
720, 722. 
Teething (see Dentition). 
Temperature (see also Fever), 11. 
as a diagnostic aid, 11. 
how to reduce, 511. 
in distinguishing the still-born from the 

dead, 43. 
normal fluctuations, 11. 
rules in taking, 11. 
variations in, 472. 
Tender nipples, 94; treatment of, 94. 
Tenesmus, in colicystitis, 419; in dysentery, 
282; in intussusception, 319; in vesical 
calculi, 420. 
Tertian intermittent fever, 706. 

double, 706. 
Testicle, in hydrocele, 397; in orchitis, com- 
plicating mumps, 758. 
tuberculosis of, 519. 
undescended, 399. 
Tetanic seizures in rachitis, 346. 
Tetanus, 800. 
antitoxin, 801. 
bacteriology, 800. 
etiology, 800. 
pathology, 800. 
prognosis and course, 801. 
treatment, 801. 
Tetany, 798. 
course, 799. 
etiology, 798. 
prognosis, 799. 
symptoms, 799. 
treatment, 799. 
Trosseau's sign in, 799. 
Thermometer, bath, 18. 

clinical, disinfection of, 934. 
Thirst, excessive in diabetes insipidus, 416; 
in diabetes mellitus, 419; in gastric 
catarrh, 243; in gastro-duodenitis, 250. 
in diarrhoea, 274. 
Thoracoplasty in chronic empyema, 471. 
Thorax, depression of, in rachitis, 346. 
in empyema, 468. 
spindle-cell sarcoma of, 884. 
Threadworms, 329. 
Throat, as diagnostic aid, 13. 
diseases of, 425. 
ice-bag, 434. 

in diphtheria, 558; in gastro-duodenitis, 252; 
in rubella, 623; in scarlet fever, 647, 670. 
spray, 434. 
Thrombosis, in diphtheria, 550; in gangrene, 
881. 
of cerebral sinuses, 860. 
of pulmonary artery, 559. 
Thrush (see Stomatitis Mycosa), 225. 

resembling diphtheria, 558. 
Thymic asthma, 773. 
Thymo-chloroform oil (Morris's), 880. 



INDEX. 



i i 



Thymus, 753. 
diseases cf, 77:!. 
enlarged, 75:!. 

primary tuberculosis of, 519. 
Thyroid, abnormality of, 773. 
desiccated, extract of, in cretinism, 771. 
implantation, 772. 

in exophthalmic goiter, 772; in leukaemia, 
735. 
Thyroiditis acute. 773. 
Tibia, in rachitis, 348. 
Tic, 7^7 
Tinea tonsurans, 878. 

versicolor, S73. 
Tongue, as diagnostic aid, 13. 
bifid, 232. 
depressor, 14. 

epithelial desquamation of, 231. 
hypertrophy of, congenital, 232. 
in chorea, 78S; in cretinism, 760; in diph- 
theria, 551, 553; in gastritis, chronic, 
253; in glossitis, 232; in measles, 630, 633; 
in rubella, 623; in scarlet fever, 647. 
tubercular infection of, 519. 
ulceration of, in pertussis, 488. 
Tongue-tie, 55. 

Tonics, restorative, 667; nutritive, 205. 
Tonsillaris, angina, 430. 
Tonsils, enlarged, 435. 

causing bronchial asthma, 455. 
indications for removal, 435. 
predisposing to laryngeal stenosis, 599. 
in diphtheria, 551, 553; in leukaemia, 735. 
tuberculosis of, 437. 
Tonsillitis, 430. 

bacteriology, 430. 
pathology, 430. 

sequelae, chorea, 788; rheumatism, 741. 
significance of, 431. 
symptoms, 430. 
treatment, 431. 
croupous, 432. 
follicular, 431. 
hypertrophic, chronic, 434. 
phlegmonous, 433. 

ulcero-membranous, 432. 
Tonsillotomy Baginsky, 436: Mackenzie, 436. 
Tonsillotomy, 436. 
bleeding following, 435, 436. 
indications for, 435. 
Top-milk, 137. 
Torticollis, 746. 

etiology, 746. 
symptoms, 747. 
treatment, 747. 
medicinal, 747. 
surgical, 747. 
acquired, 746. 
acute, 746. 
chronic, 746. 
congenital, 746. 
ocular, 746. 
psychical, 746. 
rachitic, 746. 
spasmodic, 746. 



107. 
the 



Toxaemia, in auto-intoxication, 319; in dysen- 
tery, 282. 
interstitial, causing tetany, 798. 
Toxin, diphtheria, effect of, on nervous sys- 
tem of animals, 549, 550. 
in scarlet fever, 647, 650. 
Toxins (see Poisons), 
causing convulsions, 781 
elimination of, 576. 
Trachea, cannula, silver, 616; hard rubber. 
616. 
stenosis of, 581. 
Tracheotomy, in laryngeal stenosis, 615. 
operation, 616; anaesthetic, 616. 
after-treatment, 617. 
in syphilitic sub-glottic stenosis, 721. 
Trachoma (see Granular Ophthalmia), 864. 
Transamination of stomach, 255, 256. 
Traumatism, causing acute arthritis, 903; 
aphtha?, 16, 225; cerebral abscess, 843; 
epilepsy, 802; joint disease, 901. 
Trophonine, as a substitute food, 156. 
Tropon, 206. 

Trosseau s sign in tetany, 799. 
Truss, in umbilical hernia, 323. 
Trypsin ferment test, 250. 
Tubercle bacilli, disseminated by cows. 
in tubercular perinephritis, 410; in 

urine, 920. 
stain for, in sputum, 928. 
transmission of, 520. 
Tubercular empyema, 471. 
hip-joint disease, 898. 
meningitis, 819. 

ulceration of the intestine, 538. 
Tuberculin test, for diagnosis, 334, 533. 
cutaneous reaction (Pirquet), 533. 
of pure bred cattle, 106. 
ophthalmo reaction (Calmette), 533. 
Tuberculosis, following cerebral pneumonia, 
509; chlorosis, 738; empyema, 471; 
scrofulosis, 517. 
in the new-born, 52, 517. 
manifestations in bladder, 421. 
modes of infection, 115, 518. 
mortality statistics. 524, 527, 528, 529. 
ratio of, between the whites and 
colored, 525, 526. 
of hip-joint, 898. 
of pericardium, 378; diagnosis, 378; 

treatment, 378. 
of tonsils, 437. 
predisposing causes, 519. 
acute, 516. 

bacteriology. 519. 
diagnosis, 532. 

from faulty metabolism, 334; from 
syphilis, 721; from typhoid, 532. 
sputum, 532; blood in, 535. 

method of o'btaining, 532. 
tuberculin reaction, 533. 
etiology, 516. 

cows' milk, 115. 516. 



f 



978 



INDEX. 



Tuberculosis (concluded), 
raw milk, 517. 
woman's milk, 516. 
pathological anatomy, 521. 

lung, 521, 523. 
prognosis, 533. 
symptoms, 530. 
anaemia, 530. 
cyanosis, 530. 
night sweats.. 535. 

physical signs, 530; in nurslings, 531. 
resembling intermittent fever, 530. 
temperature, 530. 
treatment, 534. 
diet, 534. 
general, 534. 
hygienic, 534. 
medicinal, 535. 
bovine, 516. 

chronic pulmonary, 535. 
mortality, 524. 
pathology, 536. 
lesions, 536. 
lung, 537. 
symptoms, 537. 
anaemia, 538 

dyspnoea and cyanosis, 538. 
expectoration, 538. 
pleuritic pains, 538. 
treatment, 538. 
miliary (see Acute). 
Tuberculous adenitis, 442. 
ankle-joint disease, 902. 
broncho-pneumonia, 535; coxitis, 899. 
elbow-joint disease, 902. 
hip-joint disease, 898. 
infection through milk, 105, 115, 516. 
knee-joint disease, 901. 
nodules, 820. 
pneumonia, 514. 

following diphtheria, 515; measles, 515; 
whooping-cough, 515. 
wrist-joint disease, 902. 
Tumor of bladder, 421. 
of intestine, 285. 
of kidney, 414. 
sacral, congenital, 58. 
spindle-cell sarcoma of thorax, 884. 
spongy (see Angeioma), 53. 
Tunica vaginalis, hydrocele of, 397. 
Turbinates, hypertrophied, 455; causing bron- 
chial asthma,, 455. 
Turpentine stupes, 937. 

Twitching, in chorea, 788; in meningitis, 822. 
Tympanites (see Intestinal Colic), 293. 
a symptom of worms, 325. 
complicating typhoid, 698. 
in intussusception, 321. 
Typhoid bacillus in perinephritis, 409. 
fever, 689. 

bacteriology, 690. 

complications, 698; aphasia, 698: chorea, 
698; otitis media, 698; peritonitis, 698. 
course, 698. 
diagnosis, 694. 



differential, 696; from cholera infan- 
tum, 696; from diarrhoea, 697; 
from malaria, 696. 
eruption, 695. 
etiology, 689. 
foetal and infantile, 691. 
internal haemorrhage, 697. 
intestinal perforation, 687. 
leucopsenia in, 696. 
mortality, 690. 
pathology, 690. 
prognosis, 698. 
sequela, tetany, 798. 
symptoms, 693. 

temperature, 693. 
treatment, 698; bath, 699, 732; food, 700. 

Uffelmann's test for lactic acid in stomach- 
contents, 915. 
Ulcer, in scrofula. 724; in syphilis, 724. 
of frenum of tongue, 488. 
of stomach, 258. 738. 
diagnosis, 527. 
prognosis and course, 258. 
symptoms, 258. 
treatment, 259. 
of tonsil, 432. 

tubercular of intestine, 538. 
Ulcerations, aphthous, 223. 

due to wearing of intubation tube, 596. 
Ulcerative proctitis, 329. 
Ulcero-membranous tonsillitis, 432. 

resembling diphtheria, 558. 
Umbilical cord, 16; haemorrhage of, 38. 
after-treatment, 17. 
haemorrhage in syphilis, 719. 
hernia, 322; causes, 322; treatment, 322. 

following pertussis, 489. 
polypus, 34. 
Umbilicus, bleeding from, 33. 
in Meckel's diverticulum, 34. 
management of, 16. 
Undescended testicle, 399. 

Undiluted milk as a food for infants, 115. 
Unna's soft zinc paste, 870. 
Uraemia in post-scarlatinal nephritis, 659. 
Uraemic convulsions in nephritis, complicat- 
ing diphtheria, 552. 
Urea in diabetes insipidus, 416. 
Urethra in vaginitis, 402. 
Urethral calculi, 420. 
Urethritis, 400. 
Uric acid, in the blood, 750. 

in urine, 920; of new-born, 918. 
Uricacidaemia (see Lithaemia), 750. 
Urine, 917. 
albumin in, 918; test for, 921. 
bloody, 417. 

diazo-reaction in, 923; in typhoid, 695, 697. 
disinfection of, 935; in typhoid, 700. 
fermentation test, 927. 
first, 917. 

in atrophy, infantile, 915; auto-intoxication, 
317: in colicystitis, 419; in cystitis, 421; 
in derangement of liver, 382; in diabetes 



INDEX. 



979 



Urine (concluded). 

insipidus. U6; in diphtheria, 552, 919; in 
epilepsy, 806; in gastro-duodonitis. 252; 
in glycosuria, 418; in hematuria, 417; 
in hemoglobinuria, 418; in icterus neo- 
natorum, 918; in influenza, 182; in 
leukaemia, 920; in lithaemia, 751; in 
measles, 633; in nephritis, 406, 407, 919; 
in pertussis, 4S9; in pneumonia, 508; in 
pyelitis, 412; in scarlet fever, 648, 650, 
651; in septic diphtheria, 553, 559, 562; 
in typhoid, 695, 697, 700: in tuberculosis, 
530. 

incontinence of, in multiple neuritis, 794; 
in ectopia vesicae, 413. 

indican, test for, 925. 

method of collecting, 917. 

of breast-fed babies, 917; of new-born 
babies, 918. 

sodium chloride in, 918. 

specific gravity, 921. 

sugar in, 418; test for, 925. 
I'rino-pyknometer, 920. 
Urticaria, 871. 

causes, 871. 
symptoms, 872. 
treatment, 872. 

following administration of antitoxin, 872; 
of drugs, 872. 

gastro-intestinal disturbances, 872. 
Useless coughs, 449. 
Uvula, bifid, 232. 

enlarged, causing bronchial asthma, 455. 

inflamed, in spasmodic laryngitis, 444. 
section from, 547. 

in scarlet fever, 647. 

Vaccination, 686. 

complications, 686. 
method of, 687. 

site of inoculation, 686. 
mortality of vaccinated and unvacci- 

nated, 687. 
symptoms, 686. 
accidental, on cheek, 687. 
Vaccine, varieties of, 686. 
Vaccinia, 686. 

eruption, 688. 
symptoms, 688. 
Vagina, rectum terminating in, 60. 
Vaginitis, 400. 

bacteriology, 401. 
complications, 402. 
etiology, 401. 
catarrhal, 400. 
gonorrheal, 400. 
simple; 400. 
vulvo-, 400. 

following scarlet fever, 402. 
Varicella, 676. 
complicating erysipelas, 67S. 
diagnosis, 676. 

differential, 677: from impetigo. 678; 
from variola, 677. 
etiology, 676. 



pathology, 676. 
prognosis, 678. 
treatment, 678. 
Variola, 680. 
complications, 685; broncho-pneumonia, 685; 

oedema of glottis, 685; otitis, 685. 
desquamation, 682. 

diagnosis, differential, 683; from chicken- 
pox, 685; from impetigo, 683; from scar- 
let fever, 683; from syphilis, 685; from 
typhoid, in early stages, 683. 
eruption, 681. 
etiology, 680. 
isolation, 685. 
mode of infection, 681. 
mortality, 680. 
prognosis and course, 685. 
symptoms, 681. 

stage cf decline, 680; of suppuration, 682. 
treatment, 685. 
Varioloid, 685. 
Vascular naevus, 878. 

Vasomotor disturbance, causing asthmatic at- 
tacks, 455. 
Vegetable milk, Lahmann's, 187. 
Vein, transverse nasal, in adenoid vegeta- 
tions, 439. 
umbilical, 361. 
Veins, engorgement of, in insolation, 851. 
of abdomen, in ascites, 392. 
of scalp, in hydrocephalus, 816; in rachitis, 

346. 
splenic, in malarial fever, 711. 
varicose, in chlorosis, 738. 
Velum palatinum, in diphtheria, 551, 5? ,. 
Venesection, 938. 
Venous murmurs, 368. 
Vermiform appendix, location of, 262. 
Vernix caseosa, 17. 
Verruca, SS0. 

Vertigo, a symptom of worms, 325. 
Vesical calculi, 420. 
Vicarious menstruation, 404. 
Vincent's bacillus, 433. 
Vocal resonance, 451. 
Voice, husky, in papillomata, 888. 
in pleurisy with effusion, 465; in syphilis, 

723. 
nasal, in diphtheria, 550, 562. 

with hypertrophy of tonsils, 435. 
Vomiting, chronic, 252; cyclic, 259. 
faecal, in intussusception, 320. 
in dilatation of stomach, 255; in diphtheria, 
552: in Henoch's purpura, 750; in in- 
fluenza, 480: in measles, 630; in menin- 
gitis, 822, 826; in pachymeningitis, 833; 
in pertussis, 490: in premature infants, 
31; in pyloric obstruction, 248; in 
rubella, 623; in scarlet fever, 645, 651; 
in spinal paralysis, 811; in typhoid, 693. 
significance of, 242. 
Vulvo-vaginitis, 400. 
catarrhal. 400. 
gonorrheal, 400. 

bacteriology, 401. 



980 



INDEX. 



Vulvovaginitis (concluded). 

complications, 402; eye, 402; heart, 402; 

joint, 402; pyelitis, 402. 
etiology, 40i. 
mode of infection, 401. 
treatment, 403; vaccine injections, 403. 
simple, 400. 

bacteriology, 400. 

etiology, 400. 

following scarlet fever, 402. 

prognosis, 403. 

symptoms, 400. 

treatment, 403. 

Walking, first attempts at, 2. 
in congenital dislocation of hip, 900; in 
hereditary ataxy, 809. 
Wampole's milk food, 198; analysis of, 199. 
Wandering pneumonia, 499. 

spleen, 386. 
Warts (see Verruca), 880. 

syphilitic, 725. 
Wassermann reaction in syphilis, 721. 
Wasting disease (see Athrepsia Infantum), 

356. 
Water-ices, 212. 

Water on the brain (see Chronic Hydroceph- 
alus), 814. 
Waxy liver, 383. 
Weaning, 90, 91. 
difficult, 91. 
during pregnancy, 90. 
Weighing to determine the quantity of milk 

an infant has taken, 217. 
Weight at birth, 217. 
effect of sugar on, 119. 120. 
gain in, of an infant fed on Eskay's food, 
219. 
on modified milk. 220. 
on mother's milk, 217. 
on Walker-Gordon modified milk. 220. 
of a prematurely born infant, 31. 

wet-nursed, 219. 
loss of, 333; during first week. 67. 



Weight-scale, Chatillon, 216. 

Werlhof's disease (see Purpura Haemor- 

rhagica), 748. 
Wet-nurse, 80. 

child of a, 81.' 

dangers of syphilis, 84, 227. 

diet of a, 86. 

for weak and marasmic infant, 80. 

health of a, 81. 

how to examine, 80, S2. 

manner of living, 86. 

proper rest for, 86. 

selection of. SO, 83. 

tricks of. 81. 

with goiter, 81. 
Wet-nursing, in New York, 89: in Prague, 88. 
Wheal, in urticaria, 872. 
Whey, 910. 

Whitney's test for sugar in urine. 926. 
Whooping-cough (see Pertussis), 486. 
Widal's reaction in typhoid, 694. 

stages in, 694. 
Winckel's disease, 50. 
Woman's milk (see Milk). 
Woodward's burette for estimating proteids. 

124. 
Worms, causing convulsions. 7S1, 783. 

pinworms. 326. 

round worms, 325: diagnosis. 326: treatment, 
326. 

tapeworm, 323; diagnosis, 324: symptoms, 
324; treatment, 324. 

threadworm, 326. 
Wrist-joint disease, 902. 

in rachitis, 342. 
Wry-neck, (see Torticollis), 746. 

X-ray examination, as diagnostic aid, 14. 
difficulty in making, 15. 
of congenital dislocaiton of hip, 900. 

Yawning, in malarial fever. 7f5. 

Zoolak, 209; analysis of, 209. 



OCT 10 19H 



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